
■HI 



Book 



GoipglitW l^A^ 



dSEXRIGHT DEPOSm 



HAY- FEVER 

ITS PREVENTION AND CURE 



Orifice of middle ethmoidal eel 
Superior turbmal bone 
Orifice of the posterior ethmoidal celib 

Orifice of the sphenoidal bin us, 
Sphenoidal sinu 




Orifice of 
frontal sinus 

Upper orifice 
of nasal duct 



Orifice ot KubUitliia 
tube 



Lower orifice o^ 
nasal duct 



Middle tuiuinal bone 

Inferior turbinal bone Orifice of die antrum Orifice of infundibulu 



JECriON OF THE N 



OSE, SHOWING THE TuRBINAL BoNES AND MEATUSES 

AviTii THE Openings in Dotted Outline 
(-4fter Morris' "Text-Book of Anatomy "') 



HAY-FEVER 

ITS PREVENTION AND CURE 

.// „ 

T^^dr HOLLOPETER, M.D., LL.D. 

ATTENDINO PHYSICIAN ST. JOSEPH'S HOSPITAL; PEDIATRICIAN TO 
THE PHILADELPHIA GENERAL HOSPITAL; PROFESSOR PEDIATRICS, 
EMERITUS, MEDICO-CHIRURGICAL COLLEGE; EX-PRESIDENT 
OP THE ASSOCIATION OF AMERICAN TEACHERS OF THE 
DISEASES OP children; EX-CHAIRMAN OP THE SEC- 
TION ON DISEASES OP CHILDREN, AMERICAN 
MEDICAL association; MEMBER OF AMERI- 
CAN ACADEMY OF MEDICINE, ETC. 

FOURTH EDITION, REVISED 




FUNK & WAGNALLS COMPANY 
NEW YORK AND LONDON 
1922 



^c*^ 

^^^> 



\ 



COPTEIGHT, 1916 AND 1922 BY 

FUNK & WAGNALLS COMPANY 

[Printed in the United States of America] 



Fourth EiUtiorij Published, April, 19S2 



Copyright Under the Articles of the Copyright Convention 

of the Pan-American Republics and the United 

States, August 11, 1910 



MAY 2? '22 

g)C!.A661837 



-w^ 



I 



CONTENTS 



PAGE 

Preface to Fourth Edition iii 

Preface to First Edition ix 

Introduction xi 

PAET I 

WHAT HAY-FEVER IS. HISTORY, PERIOD- 
ICITY, SYMPTOMS AND DIAGNOSIS 

1. Definition, History and Bibliography 19 

2. Causes 38 

3. Periodicity 46 

4' Symptoms 53 

5. Its Pathology, Diagnosis and Prognosis 65 

PAET II 
ACCEPTED CAUSES 

1. When Due to Some Exciting Agent Such as 

Pollen 87 

2. The Predisposing Causes 110 

PABT III 
FORMS OF TREATMENT 

1. Preventive Measures 147 

2. Local Treatment by Nasal Applications 158 

i 



CONTENTS 

PAGE 

3. As TO Diet, Exercise and Eest 165 

4. When Asthma Occurs as a Sequel 169 

5. The Use op Serums — Dunbar's Serum 172 

6. Frequent Causes and the Treatment of 

Seasonal Hay-Fever 199 

7. The Present-Day Conception of Hay-Fever. . 298 

8. Frequent Causes and the Treatment of 

Perennial Hay-Fever 311 

9. The Calcium Salt Treatment 346 

10. Surgical Treatment 353 

11. A Summary of Treatment 354 

Bibliography 359 

Index 413 



ii 



PEEFACE TO THE FOURTH 
EDITION, REVISED 

Since the last edition of my book on 
Hay-Fever, published six years ago, great 
advance has been made. The theory that 
pollen might be the cause has been at last 
demonstrated and actually proven to be a 
fact, and the works of Blackley, Wyman, 
Dunbar and Scheppegrell have at last 
crystallized into certainty. We now know 
that the emanations of vegetable matter 
actually cause hay-fever, that different 
parts of the United States produce differ- 
ent pollens, so the treatment of hay- 
fever in one portion will be different from 
the treatment in another. The West, North, 
and East, will call for a different immuniz- 
ing process than that of the Middle States, 
yet any one can prevent his annual suffer- 
ing by selecting the proper anaphylactic 
reaction from inhaled atmospheric pollens. 
While these pollens vary in different local- 
ities at various seasons, and their degree 
of reaction on sensitive subjects, yet the 
true factor can soon be found, and the un- 
[iii] 



HAY-FEVER 

fortunate victim will obtain complete re- 
lief. Hay-fever is now successfully treated 
by immunizing the patient in advance of 
the attack, by the use of the same pollen 
that creates his trouble. The only diffi- 
culty to overcome, is to be sure to find the 
pollen that produces the actual mischief. 
This is, therefore, an individual study, not 
veiy difficult if the patient works in har- 
mony vdth his physician. 

As Dr. William Scheppegrell, of New 
Orleans, a leading authority on hay-fever 
and the President of the Hay-Fever Pre- 
vention Association, says : '"Any physician 
with experience in hay-fever cases has ob- 
served the great difference in the intensity 
of the symptoms and in the reactions to 
the diagnostic tests. In some cases, the 
injection into the skin of five units will pro- 
duce a positive, but mild and transient, re- 
action while in others, the same number 
of units will produce a wheal three centi- 
meters in diameter and surrounded by a 
wide area of infection and lasting for many 
hours. In the former, with a low degree 

[iv] 



HAY-FEVER 

of anaphylaxis, the doses may be in- 
creased with comparative rapidity and 
safety, and must reach a high number of 
units in order to be effective. In the latter, 
however, the increase must be made cau- 
tiously and the maximum dose carefully 
determined. 

Another point of importance in the 
successful treatment of hay-fever is to re- 
member that all hay-fever patients east of 
Kansas are not necessarily victims of the 
Amhrosiacae (Eagweed) group; or, even 
if this is the case, that this is not the only 
cause. In a large area of the Northeastern 
States, for instance, the Russian thistle, 
Salsola pestifer, is a potential cause of 
hay-fever infestation, that should be care- 
fully considered in the successful treat- 
ment of these cases. This is especially im- 
portant, as these cases do not respond to 
the diagnostic tests of the Amhrosiacae 
group and are not benefited by the injec- 
tion of these pollen extracts. 

If the *^ extensive '^ methods of treat- 
ment are followed, in which no diagnostic 

[V] 



HAY-FEVER 

tests are made and no cognizance taken of 
the varying degree of sensitivity and the 
different kinds of pollen involved, the re- 
sult will be disappointing to the patient 
and an apparent reflection on the immuniz- 
ing method. TJie ''intensive method/^ 
however, in which all the factors bearing 
on each individual case are carefully con- 
sidered, will not only give satisfactory 
results to the patient and physician, but 
will place this method on the scientific 
basis to which it is entitled. 

Some manufacturers of pollen extracts, 
not taking cognizance of these factors, 
have attempted to simplify the immunizing 
method by preparing mixtures containing 
the most common pollens. Many of these 
contain not only pollens responsible for 
hay-fever, but even some that, for various 
reasons, the patient never has an oppor- 
tunity to inhale. The result of this ''shot- 
gun" method is that the patient usually re- 
ceives an injection containing a mass of 
inert protein that leaves the possibility of 
benefit very doubtful. 
[vi] 



HAY-FEVER 

It has been estimated that in New Eng- 
land and the Middle States, 90 per cent, of 
the June hay-fever (rose cold) comes from 
timothy grass and same percentage of the 
July and August hay-fever from ragweed. 
If this is true, then we have a safe work- 
ing basis, for our patients will tell us how 
and when they receive their infection. 
While we have found hay-fever is caused 
by the pollens of certain plants, yet for 
many years we did not know that it was 
excited by wind pollinated plants and not 
by the insect pollinated. This is an im- 
portant fact to be remembered as insect 
pollinated plants contain a noxious ele- 
ment and will give a positive skin test in 
certain individuals. For many years the 
medical profession drifted away from the 
local applications of remedies, even for the 
relief of hay-fever. I have invariably 
found much comfort and satisfaction in 
local treatment, and many of my patients 
insist on having it. Dr. G. M. Mackenzie, 
of New York, is favorably imprest with 
specific local applications. His conclu- 
[vii] 



HAY-FEVER 

sions are as follows: (1) The reactivity of 
the rasal mucosa of hay-fever patients 
may be markedly diminished by spraying 
the nose and throat with the specific pollen 
antigen. (2) In a series of patients (38) 
given specific prophylactic treatment by 
this method the results compared favor- 
ably with those in a series of patients 
treated by specific subcutaneous injections, 
but were less satisfactory than when a 
combination of the two methods was em- 
ployed. 

I am giving the article of Dr. I. Chand- 
ler Walker, of Boston, Mass., ''The Fre- 
quent Causes and the Treatment of Hay- 
Fever," in full, so the reader may study 
his personal technic. 

W. C. HOLLOPETEB. 

Philadelphia, March, 1922. 



[Tiii] 



PREFACE TO THE FIRST EDITION 

Having had remarkable and uniform 
success with a simple treatment of hay- 
fever for the last twenty years, during 
which time I have given complete relief 
to many patients in my private practise, 
and having made a thorough clinical study 
of this affection, as well as an exhaustive 
review of the literature relative to it, I 
feel justified in presenting the results of 
my labors in this short treatise. 

There is little to be said definitely about 
the etiology of the disease. It is undoubt- 
edly caused by an external irritant, pos- 
sibly containing a micro-organism or a 
toxin, which becomes especially active in 
the nasal passages of an individual pre- 
disposed by systemic debility or local 



PREFACE 

abnormality. We acknowledge the ele- 
ment of neurotic distnrbance, but to dog- 
matically define its exact cause and modus 
operandi is beyond us. 

In order that the best thought of the 
subject may be presented to the reader, 
I have compiled, arranged, and annotated 
the most worthy literature, and I acknowl- 
edge my indebtedness to the many writers 
quoted. The most of my original com- 
munication is devoted to the all-important 
point in the discussion — ^the successful 
treatment. A complete bibliography is 
appended, 

W. C. HOLLOPETER. 



[X] 



INTRODUCTION 

Next to tuberculosis, hay-fever is one 
of the most interesting and common dis- 
eases, and has received an enormous 
amount of study. While it is not directly 
fatal, it is exceedingly distressing and is 
certain by its annual visitation to lower 
the vital resistance and induce other ill- 
ness in the body. In this way it becomes 
a prolonged and serious menace to the 
comfort and happiness of the sufferer. 
Hay-fever was not regarded frequent in 
the young until a more careful study of 
autumnal and spring catarrhs among neu- 
rotic children revealed the fact that the 
same troublesome complaint had occurred 
the previous season. The frequency of 
**cold taking '* among children is due to 
their lowered vitality, the result being 

[xi] 



INTRODUCTION 

adenoids and enlarged tonsils which often 
precede the typical hay-fever. 

It has been found that children, espe- 
cially the neurotic offspring of nervous 
parents, are as subject to hay-fever as 
adults, if not more so, for we certainly 
have an ever-enlarging army of catarrhal 
children. There is no doubt that in every 
class hay-fever is decidedly on the in- 
crease in America. True hay-fever is 
also found in great masses of thoughtful 
adults, who are prone to forget the previ- 
ous attacks, altho they may have had many 
annual visitations of the disorder. Some 
slight exposure, or irregularity of diet, or 
an unusual change in the atmosphere, suf- 
fices to explain the indisposition, and satis- 
fies the mind for the time. It is certain 
that a large number of hay-fever sufferers 
forget from year to year the annual visita- 
tion ; this is more likely if the attack has 
not been severe. Furthermore, it has been 

[xii] 



INTEODUCTION 

most conclusively proved by many authori- 
ties that hay-fever does not occur unless 
we have a conjunction of three necessary 
factors : 

1. An external air-borne irritant. 

2. A sensitive or diseased nasal mucous 
membrane. 

3. An unstable nerve-center. 

Upon the simultaneous manifestation of 
these three factors in any individual we 
are reasonably sure in making a diagnosis 
of hay- fever. An absence of any one of the 
three admits at once of distinct doubt. 

The claim for originality in this thesis 
lies in the fact that the author recognizes 
the three essential factors, as stated above, 
as the cause of hay-fever, and claiming 
that the remedy lies in controlling or de- 
stroying the habit, by inhibiting or be- 
numbing the sensitive nasal surface by 
local cleansing and massage. The litera- 
ture of hay-fever has grown so very pro- 

[xiii] 



INTEODUCTION 

lifically in the last ^ve years that to follow 
it out in detail would be a difficult and use- 
less task. Most writers agree as to the 
three essential causative factors, and vol- 
umes have been written in discussion of 
their different phases. 

Dr. Geo. M. Beard, one of the earlier 
and most exhaustive writers, regards it as 
a neurosis, due to an unstable brain-center, 
and a functional disease of the nervous 
system, thus ignoring all environment, 
climate and nasal conditions. Sajous, on 
the other hand, regards the trouble as one 
of local origin, ignoring heredity and neu- 
rosis, and finds an abnormal nasal chamber 
in all active cases. They both concede ex- 
ternal irritants as essentially necessary to 
the initial paroxysm, but regard this of 
secondary importance. It was not until 
Prof. Dunbar and his followers made their 
exhaustive studies of pollen that we ar- 
rived at any satisfactory scientific knowl- 

[xiv] 



INTEODUCTION 

edge as to the exact nature of this *' ex- 
ternal irritant/' and applied the antidote 
for its control. Literature on hay-fever 
during the past ten years has centered 
largely on discussion of these studies. It 
is for this reason that I have given Dun- 
bar so large a space in my book. I have 
allowed him to speak for himself. 

In my first published paper in 1898, I 
stated that I had succeeded in controlling 
a large number of cases by '^scrubbing 
most carefully every portion of the mu- 
cous membrane of the nasal chamber, be- 
ing sure to reach between the turbinated 
bones and all around any slight promi- 
nence." Musser and Kelly (^* Practical 
Treatment," 1913, Saunders, Philadel- 
phia) quote E. W. Wright as placing 
great stress upon the hypersensitive condi- 
tion of the nasal mucosa as the important 
causative factor in many cases, suggest- 
ing a frictional massage of the mucous 

[XV] 



INTEODUCTION 

membrane of the nose in order to in- 
crease its resisting powers, so that it can 
withstand the irritation and excitation 
from the impact of the pollen of plants. 
His method is to apply gentle massage 
to the nasal mucons membrane through 
the medium of a cotton-covered probe. 
These applications are to be made daily 
for from three to five minutes in each 
nasal chamber. 

I am unable to find any additional au- 
thority for this method of management of 
the disease. The observation of Wright 
was made long after the publication of 
my paper; and certainly priority for such 
local treatment belongs to me. 



[xvi] 



PART I 
WHAT HAY-FEVER IS 

HISTORY, PERIODICITY, SYMPTOMS 
AND DIAGNOSIS 



117] 



PART I 
WHAT HAY-FEVER IS 

HISTORY, PERIODICITY, SYMPTOMS 
AND DIAGNOSIS 

1. Definition, History and Bibliography 

Among the synonyms that have been 
employed for the term hay-fever may be 
named the following: Antnmnal catarrh, 
Bostock's catarrh, coryza vasomotoria, 
coryza vasomotoria periodica, hay-asthma, 
idiosyncratic coryza, June cold, July cold, 
nervous coryza, nervous catarrh, paroxys- 
mal sneezing, peach cold, periodic hyper- 
esthetic rhinitis, pollen catarrh, pollen 
poisoning, pruritic catarrh, pruritic rhi- 
nitis, ragweed fever, rhinitis sympathetica, 
rhinitis vasomotoria, rose catarrh, rose 

[19] 



HAY-FEVEE 

cold, summer bronchitis, summer catarrh, 
summaer catarrh from idiosyncrasy, smn- 
mer fever, typical early summer catarrh, 
vasomotor coryza, vasomotor rhinitis. In 
other language are the following equiva- 
lents: Latin — Catarrhus sestivus, coryza 
vasomotoria periodica; French — Catarrhe 
d'ete, catarrhe de foin; Oerman — Friih- 
sommerkatarrh, Heuasthma, Heufieber ; 
Italian — Asma dei mietitori, febbre del 
fieno, asma del fieno. 

The term ** hay-fever" was first used to 
designate the form of disease occurring in 
the autumn in distinction from like affec- 
tions which occur in other seasons. So 
universal, however, has become its use that 
it is now employed to designate all the 
forms of what may be called the periodic 
influenzas, irrespective of seasons. 

Hay-fever may be defined as an affec- 
tion of the upper air-passages occurring 

120] 



WHAT HAY-FEVEE IS 

periodically, usually at or near a fixt 
date in tlie early autumn, sometimes in the 
spring or summer, characterized by its 
sudden onset and as sudden termination in 
certain atmospheric conditions, by swell- 
ing and turgescence of mucous membranes 
of the nasal fossse and adjacent cavities, 
irritating discharges therefrom, and vari- 
ous symptoms of coryza, and occasionally 
by asthmatic paroxysms. It always re- 
sults from the combination of a special 
predisposition, from depraved resistance 
or lowered vitality of the general system 
or a local lesion, and an exciting cause, 
believed to be a micro-organism or pecu- 
liar toxin, generally arising from pollen 
or dust deposited upon or in the mucous 
membrane of the upper air-passages. The 
important predisposing causes are : hered- 
ity, idiosyncrasy, neurotic temperament, 
peculiar susceptibility of the vasomotor 

[21] 



HAY-FEVER 

system, generally debilitated condition, 
deranged assimilation, and a local lesion. 
Hay-fever has been defined as a neurosis, 
as an idiosyncrasy, as a catarrhal affec- 
tion, and as a type of influenza, and as 
various combinations of these. The de- 
position of some special irritant is uni- 
versally regarded as the exciting cause. 

Exactly when hay-fever was recognized 
as a distinct affection is not known. Bes- 
chorner shows that it was known in the 
sixteenth century. In 1565 Botallus re- 
ported a case. Van Helmont and Binnin- 
ger, in the seventeenth century, speak of 
it. A similar distressing catarrhal affec- 
tion, but due to the rose, is instanced in 
**Acta nat. curios. Ephemerides, " Dec. 
n, Ann. V, obs. 22, and again in the same 
journal, Dec. Ill, Ann. V and VI, obs. 
193, a case of annually recurring profuse 
nasal catarrh is mentioned. John Floyer, 

[22] 



WHAT HAY-FEVER IS 

London, 1698, noticed that there were 
peculiar cases of asthma in which the at- 
tacks were longer and more acute in sum- 
mer than in winter. In Good's "Study 
of Medicine" there is a reference to a 
case related by Timseus in 1667, of an at- 
tack of an asthmatic nature caused by the 
odor of roses and ipecac. Eiedlin, in his 
"Lin. Med.,'' p. 177, in 1695, wrote of the 
odor of roses causing a catarrh of the 
head, resembling hay-fever. C. L. Parry, 
of London, records a case in 1809 and an- 
other in 1811. EUiotson, in 1821, tells of 
a patient who had had hay-fever since 
1789, and of another who was sixty-six 
years of age and who had had the disease 
from his seventh year, i.e., since 1755, and 
of a third who had been afflicted for many 
years. 

Just when and where the term "hay- 
fever" or "hay-asthma" arose it is im- 

[23] 



HAY-FEVER 

possible to say, but probably it was popu- 
larly so named. The emanations from dry 
hay were first tbougbt to have caused it. 
Dr. Bostock, wbo was himself a sufferer, 
in 1819, found that the laity knew of the 
a:^ection, altho it was not recognized 
as a distinct disease by the profession. 
He objected to the term ** hay-fever," 
which was already employed to designate 
it in his day, contending that moist heat, 
sunshine, dust, and fatigue were more 
potent in its causation than emanations 
from dry hay. It seems remarkable that 
the profession in England were unfamiliar 
with hay-fever as a distinct affliction, es- 
pecially as their king, George IV, was a 
sufferer from it. In 1828, Bostock, who 
had first described the disease to the 
Medico-Chirurgical Society of London as 
a **case of a periodic affection of the eyes 
and chest," published some further ob- 

[24] 



WHAT HAY-FEVER IS 

servations on the complaint under the 
title ^* Summer Catarrh," or **Catarrhiis 
^stivus." In 1828, MacCuUoch included 
it in his ^*An Essay on the Remittent and 
Intermittent Diseases," but advanced no 
special views. In 1830, Augustus Prater 
published notes of a case seen in Paris. 
In 1831, Dr. Elliotson, in London, briefly 
described the affection; and in 1833 he 
discust the complaint more fully and 
opposed Bostock's theory of heat and re- 
jected the hay-theory of its origin, but 
declared grasses to be more important 
factors; and he first pointed to pollen as 
the probable cause of the disease. In 1847, 
Dr. Ramadge detailed reports of cases and 
believed ** effluvia from flowers" caused it. 
In 1850, Gream first alluded to dust as an 
exciting cause and proposed nux vomica 
as a remedy. In 1852 Dr. Laforgue, of 
Toulouse, wrote his essay ** Observation 

[25] 



HAY-FEVEE 

de catarrhe d'ete/' in wMch lie upheld 
heat as the cause, after the view of Bos- 
tock. But in the next year, 1853, in 
"L'Abeille Medicale," an anonymous con- 
tributor, reciting his own case, advocated 
hay-emanations and not heat as the excit- 
ing agent. In 1854 Phoebus, of Giessen, 
concluded from his study of 154 cases that 
sunlight was the active cause of the at- 
tacks. In 1857 Watson ascribed the mal- 
ady to the presence of vegetable matter 
in the atiHo sphere. In 1859 Phoebus again 
published the results of his circular of in- 
quiry. He went into the subject more 
thoroughly than any of his predecessors, 
and from sunlight he shifted to ozone as 
the theoretic cause of the malady. In this 
same year Hyde Salter named as the ex- 
citing agents * ^bright, hot, dusty stm- 
shine,'' a full meal, and hay, and recited 
two interesting cases. Another writer, 

[28] 



WHAT HAY-FEVER IS 

Walshe, in tke same year, referred to hay- 
fever as a singular variety of nasopnl- 
monary catarrh, and he first called atten- 
tion to the fact that the disease, in his own 
person, ** always disappeared in crossing 
the Atlantic.'' 

In July, 1860, Dr. Cornaz, of Nenf chatel, 
Switzerland, in a paper on hay-fever, de- 
scribed six cases, and concluded that the 
flowers of grasses were the cause of the 
disease, and he was followed on the 20th 
of August of the same year by Dr. La- 
bosse, of Nitry, France, in a paper en- 
titled *'Nouvelle observation de catarrhe 
de foin,'' in which he spoke of three per- 
sons whose symptoms occurred at the time 
certain flowers were in bloom. In 1866 
strong light and great heat were advanced 
as aggravating causes by JDr. iWm. Ab- 
botts Smith. In his published ^ork, ^^On 
Hay-fever, Hay-asthma, or Summer Ca-, 

[27]. 



HAY-FEVER 

tarrh," lie rejected the ozone theory of 
Phoebus. 

In 1867 the nervous origin of the dis- 
ease was first advanced by Dr. William 
Pirrie, who spoke of two forms, — one a 
spasmodic form caused by external irri- 
tants, the other arising from the action of 
light and heat upon the central nervous, 
the cerebrospinal, and sympathetic sys- 
tems. In the same year, Helmholtz, who, 
tho not a general practitioner, while 
suffering from hay-fever, began to treat 
it with a quinin solution and foimd that 
he was relieved thereby. Two years later 
he detailed to C. Binz, of Bonn, Germany, 
by letter, the history of his sufferings, and 
recommending his solution as a ready 
means of relief and even of prevention, 
which was in accord with the findings of 
Binz that the quinin solution was poison- 
ous to infusoria. In this letter Helmholtz 

[28] 



WHAT HAY-FEVEB IS 

propounded the theory that the .symp- 
toms were caused by vibrios which, tho 
latent at other times in the nasal fossae 
and sinuses, were excited to activity by 
the heat of summer. It has since been 
thought that the organisms found by 
Helmholtz, by means of the microscope, 
in the nasal discharges during an attack 
were probably fragments of mycelium-like 
threads which develop from pollen-cells 
under the influence of the heat and mois- 
ture of the nasal chambers and which con- 
tain the minute fovilla of the pollen-cells. 
The use of the quinin solution which Helm- 
holtz so successfully employed on himself 
became very popular and found many 
strong advocates in the profession until 
the extensive researches of Blackley in re- 
gard to poUen in 1873. In the meantime, 
in 1870, Dr. George Moore advocated a 
complex theory of the disease, really com- 

[29] 



HAY-FEVEK 

binations of preceding theories. In the 
same year Boberts issued a short, practi- 
cal paper, claiming to be the first to ob- 
serve excessive coldness of the tip of the 
nose as the '* pathognomonic" symptom 
of hay-fever and desiring credit to be 
accorded him for this discovery. 

In 1872, Morrill Wyman, of Cambridge, 
Mass., distinguished two different forms 
of the disease; naming that occurring in 
August '* autumnal catarrh," peculiar to 
America, and that of the spring or early 
summer ** June cold" or ** rose-cold," more 
prevalent in England. 

Dr. Wyman first attempted to define the 
geographical limits of the disease, and 
called attention to the important fact 
that residence in certain elevated regions 
brought certain and complete relief in 
moM cases of autumnal catarrh. He 
stated that a lady from Lynn, Mass., a 

[ 30] 



WHAT HAY-FEVER IS 

great sufferer, accidentally observed in 
1853 that her catarrh passed by while she 
was traveling in the White Mountains, 
and that for the following ten years she 
visited the region and escaped the disease. 
In 1860, Jacob Horton, of Newburyport, 
Mass., wrote Dr. Wyman that the White 
Mountains gave the only relief. In 1873, 
Charles H. Blackley, of Manchester, en- 
deavored to show that pollen mainly, if 
not exclusively, caused the malady, and 
by extensive experiments showed that the 
amount of pollen in the atmosphere at 
great elevations was to that in the air at 
ordinary breathing levels as nineteen to 
one. He proved, by very ingenious and 
carefully conducted series of experiments, 
that the pollen of grasses and flowers was 
the sole cause of hay-fever in himself, and 
that in two other patients the severity of 
the attacks was directly related to the 

[31] 



HAY-FEVER 

amoTint of pollen in the air. His snb- 
sequent observations made it extremely 
probable that pollen is an important factor 
in the causation of bay-fever, altbo all 
kinds of dust may be sufficiently irritating 
to excite tbe paroxysms. Tbis was in op- 
position to tbe views of Pboebns and of 
Pirrie, botb of wbom suggested beat, 
strong ligbt, and ozone as tbe exciting 
causes. Pirrie bad also suggested disturb- 
ance of tbe central nervous system as an 
important etiologic factor. He was sup- 
ported in tbis view in 1876 by Morrill Wy- 
man, tben of New York. In tbe same year 
Beard, of New York, published bis mono- 
graph, tbe information for wbicb bad been 
painstakingly gathered from replies to 
two hundred circulars which be bad issued 
to medical men all over America, some- 
what after the manner of Phoebus; al- 
tbo, unlike Phoebus, Beard bad himself 

[32] 



WHAT HAY-FEVER IS 

seen and treated many cases. From his 
data lie drew the conclusion that the im- 
mediate exciting causes were more than 
thirty in number, and that secondary 
causes might increase this list to more 
than one hundred. He showed also from 
his statistics that the nervous tempera- 
ment existed in a great proportion of the 
sufferers, and that nerve tonics were of 
some value. In 1877, Marsh, of Tuckerton, 
New Jersey, published an essay in which 
he accepted completely the pollen theory. 
He first called attention, in this paper, to 
the activity of the pollen of Ambrosia 
artemisicefolia, or common ragweed, as 
by far the most active of the pollens in 
America in producing the attacks. 

In 1882, Daly, of Pittsburgh, first called 
attention to the fact that a diseased con- 
dition of the nasal cavities was an impor- 
tant factor in the production of the exacer- 

[33] 



HAY-FEVER 

bations of the disease. Roe, of Rochester, 
in 1883, advocated the same theory, but 
added that *' removal of the diseased tissue 
removes susceptibility to future attacks," 
In the same year, Sajous' essay appeared 
in which he advanced idiosyncrasy as a 
heretofore unconsidered element in the 
cause of hay-fever, and laid stress upon 
the three essential factors in the produc- 
tion of an attack; viz., first, an external 
irritant, second, a predisposition of the 
system, and, third, a vulnerable or sen- 
sitive area. In 1883, Hack accepted the 
local theory of the causation of the dis- 
ease. In 1884, Harrison Allen, of Phila- 
delphia, attributed the affection to a per- 
manent or temporary obstruction of one 
or both nasal chambers. In the same year, 
J. N. Mackenzie, of Baltimore, termed the 
disease **coryza vasomotoria periodica," 
because it is essentially a coryza. He 

[34] 



WHAT HAY-FEVER IS 

says: **The well-recognized, but imper- 
fectly tmderstood personal susceptibility to 
certain forms of local irritation, wbicb is 
the sad prerogative of sufferers from this 
disease, has always been the stnmbling- 
block in its investigation and the rock 
upon which the various speculations as to 
its nature have been wrecked." He dem- 
onstrated that *Hhere exists in the nose a 
well-defined sensitive area whose stimu- 
lation, through a pathologic process or 
through ah extra irritation, is capable of 
producing an excitation which finds its ex- 
pression in a reflex act ot in a series of 
reflected phenomena." He thus claimed 
functional derangement of nerve-centers 
as essential to the disease. It was also in 
1884 that Sir Morell Mackenzie asserted 
that the universal cause of the disease was 
pollen, altho he did not deny that other 
irritating particles, e.g., ipecac, if per- 

[35] 



HAY-FEVER 

sistently brought in contact with the mu- 
cous membrane of the nasal chambers, 
may produce it. 

In 1885 Seth S. Bishop advocated the 
uric acid theory of the origin of the dis- 
ease. 

In 1887 Sir Andrew Clark, in the Caven- 
dish Lecture in London, emphasized the 
doctrine of the three great causative fac- 
tors, — ^viz., first an exciting agent, gener- 
ally pollen; second, the neurotic habit; 
and, third, a local morbid condition of the 
nasal mucous membrane. 

Since then many articles have appeared 
upon the subject, but no striking innova- 
tions in the possible etiology of hay-fever 
have been offered. 

In 1893, Macdonald said, we ought not 
to describe hay-fever as a disease but 
merely as a train of symptoms — a train 
of Dhysiologic reflexes instigated by an 

[36] 



WHAT HAY-FEVER IS 

unwarrantably small provocation in cer- 
tain individuals more susceptible to the 
influence thereof than the rest of their 
kind. 

Early in 1897, Grayson, of Philadelphia, 
stated that **the neurotic habit may exist 
but is not essential to the disease, and the 
nervous system is implicated as a victim, 
not as a culprit." He claimed that hay- 
fever is a defect, not of the nervous, but 
of the nutritive system, believing that the 
digestive tract is the cradle of the sys- 
temic error. 

In October, 1897, Edmund W. Holmes, 
of Philadelphia, stated his belief to be 
that hay-fever was largely a neurosis, 
originating in local disease of the naso- 
pharynx, the characteristic manifestations 
being in part direct, the result of central 
nervous modifications, and in part reflex, 
from the action of various mechanical ir- 

[ 37 ] 



HAY-FEVEE 

ritants, aided by local and constitutional 
factors when they exist, and by seasonable 
and climatic influences, the periodic and 
peripheric susceptibility being in partic- 
ular expressions of certain impressions. 

2. Causes 

The idea of an external irritant in hay- 
fever pervades most views of it. There 
can be no doubt, however, that there is 
usually an underlying systemic condition 
which renders individuals susceptible to 
the disease. It may, in addition, be ac- 
cepted as conclusive that the nasal ab- 
normalities found in hay-fever subjects 
are as often incidental as causative. They 
are seldom exclusively provocative of the 
susceptibility, and they are not the results 
of repeated attacks. Exactly what this 
xmderlying condition of susceptibility is 
has been variously regarded. The nature 

[38] 



WHAT HAY-FEVER IS 

of the irritant has been widely and scien- 
tifically investigated. While all theories 
advanced are in part more or less tenable, 
none of them alone is satisfactory. The 
condition is always, however, one of low- 
ered resistance, general or local. If gen- 
eral, it may be of nenrotic, lithemic, idio- 
syncratic, gastric, intestinal, or diathetic 
origin. It is, therefore, my belief, that in 
hay-fever there is always, first, an excit- 
ing agent, and, second, a system predis- 
posed by debiUty of some character to the 
inflnence of this irritant. The overwhelm- 
ing testimony as to the character of this 
irritant points to its derivation from some- 
thing external to the body of the su:fferer. 
Moreover, it is absolutely certain that 
without the action of an external irritant 
genuine hay-fever does not occur. The 
elaborate and ingenious experiments of 
Blackley, not only upon himself but upon 

[39] 



HAY-FEVEE 

otlier individuals, clearly indicated the 
pollen of flowering plants as an active, 
exciting cause. It has never been shown 
that, altho pollen, healthy or unhealthy, 
may be a mechanical irritant and thus 
account for many cases, it is not also 
a chemic irritant when it has fallen upon 
a susceptible soil. It has been claimed 
that hay-fever is caused by a toxin gener- 
ated by a fermentative process in the 
pollen which has fallen into the alkaline 
solution of the nose; and it has been 
shown that acid solutions stop the move- 
ments of many micro-organisms and sper- 
matozoa, and that alkaline solutions in 
the nares have given little or no benefit in 
attacks of hay-fever. It has also been 
shown that the affection is more com- 
mon among men than among women, and 
that the blood of the latter is the less 
alkaline. 

[40J 



WHAT HAY-FEVER IS 

Arnold, in 1896, stated that just what 
constitutes the irritant is not determined, 
and said it is likely that not healthy pollen 
but some fungoid growth is responsible, 
since threshers of grain, at other times 
without ill-effects, have complained of at- 
tacks of hay-fever after threshing smutty 
or moldy grain, especially oats. 

Helmholtz, himself a sufferer from hay- 
fever, discovered peculiar micro-organ- 
isms in his nasal discharges. These vib- 
rios were never found by others, and this 
fact is supposed to controvert his theory. 
It has not been shown conclusively that 
they have been sought for by other inves- 
tigators, and it is likely that they have 
not, since attention has been called away 
by the pollen and other theories. The 
antiseptic quinin solution employed by 
Helmholtz, while extensively used with 
good results for the subsequent decade, 

[41] 



HAY-FEVER 

was not invariably accompanied by re- 
lief. Later, the relief that was given by 
qninin solutions was said to be psychic. 
This allegation may well be understood 
when it is considered that many other 
theories as to the causation of hay-fever, 
particularly the pollen, abounded soon 
after Helmholtz's expositions. 

Some very interesting investigations by 
Strangways, of St. Louis, in 1897, urged 
him to conclude the amount of pollen in 
the air is altogether too small to have an 
injurious mechanical, medicinal, or poi- 
sonous influence. He calculates that for 
every square foot of surface there is one 
ragweed, and inquiry showed that mere 
elevation of several hundred feet above 
the earth's surface does not give relief 
from this distressing affection. Strang- 
ways found that ragweed pollen proba- 
bly floats to 1,000 feet elevation ; but, if the 

[42] 



WHAT HAY-FEVER IS 

limit is placed at 500 feet, it would give 
for every plant 500,000 cubic feet of air, 
not for one day but for six weeks ; i.e,, if 
the wbole plant was pollen there would 
be still only one part of pollen to fifteen 
or twenty billion parts of air. The rose 
and the goldenrod are in even smaller 
quantities. Strangways' estimates showed 
that there was not more than one grain of 
pollen for every thirty respirations. He 
advanced the theory that, while pollen 
plays a part, it does not irritate mucous 
membrane nor produce vasomotor paresis 
by its direct influence, but that a proto- 
plasmic substance found in pollen and in 
the vegetable kingdom, acting as a fer- 
ment, causes the formation of a toxin 
which is the real exciting cause. 

There can be little doubt that the neu- 
rotic element has been present in many, 
if not most, cases of hay-fever, and evi- 

[43] 



HAY-FEVER 

denced by depression, general lowering of 
tone, or exhaustion of the nervous sys- 
tem. The neurosis need not be acquired; 
in fact, it is often hereditary, which will 
be discust later. 

Holmes believes the disease to be in 
great part a neurosis with other debili- 
tating conditions. The fact that the bet- 
ter educated classes are most prone to 
this affection indicates the influence of 
neurotic tendency as well as exhaustion of 
the nervous system or debility or depres- 
sion thereof. The premonitory symptoms 
of this a:ffection, as ably shown by Sajous, 
show the neurotic elements. He well asks, 
**If the local irritant is the only cause, 
why does the respiratory tract, the por- 
tion of the body first and most exposed 
to its effects, not become immediately 
influenced?" This author also shows a 
case following enteric fever, the debilita- 

[44] 



WHAT HAY-FEVER IS 

ting and exhaustive character of which is 
well known, one preceded by malarial 
fever and another by bronchitis, pertus- 
sis, and varicella. 

Of the various other theories advanced 
are the lithemic, the intestinal or gastric, 
due to lack of proper assimilation, and the 
uric acid diathesis. The views herein ad- 
vanced are not at all inconsistent with the 
idea that the diatheses exercise a predis- 
posing influence in producing the affec- 
tion, which influence is debilitating and 
devitalizing. 

The local theory alone is not conclusive 
nor satisfactory; viz., that the disease is 
due to chronic nasal catarrh, or a local 
lesion, upon which the exciting cause acts. 
There is no doubt that diseased areas are 
more sensitive to the irritant, and espe- 
cially so in cases of lowered vital energy 
and lessened normal resistance, general or 

[45] 



HAY-FEVER 

local; but a large number of cases show 
no local disease. 

In all of the theories respecting this af- 
fection there is more or less regard for 
the agency of pollen in provoking the 
paroxysms of the disease; but as every 
one is exposed to the irritant, in those af- 
fected the soil must be prepared for the 
seed, that is, before the deposition of the 
pollen or dust or exciting agent there 
must be a morbid condition preexisting, 
which can so far be characterized as to 
call it lowered vitality or general or local 
resistance, which springs from a variety 
of causes. 

3. Periodicity 

On the continent of Europe, where it 
is less frequent, and in England, hay- 
fever prevails in June and July. The in- 
itial attacks occur during May and June 
and seldom last longer than September. 

[46] 



WHAT HAY-FEVER IS 

In India the malady chiefly occurs in Feb- 
rnary. In Australia, in and around Ade- 
laide, where the disease prevails, it oc- 
curs chiefly in September during the time 
of the blossoming of the Cape weed. In 
his work on hay-fever. Beard essays to 
show how the autumnal form is peculiar 
to the United States. One cause seems to 
be the flowering of the Roman wormweed 
and the pollen of corn about the middle of 
August, and another in the prevalence of 
the "dog-days." A third reason lies in 
the fact that there is less atmospheric 
ozone and electricity at this period than 
at any other time of the year, and, again, 
the hottest days are frequently in the lat- 
ter part of June. Beard also attached 
importance to a variety of hay-fever in 
which the attacks came on in September. 
This distinction is probably due to the 
fact that while one person is liable to the 

[47] 



HAY-FEVEE 



action of one pollen, another may be af- 
fected by a totally (liferent pollen, and 
the annual attacks come on when the at- 
mosphere is permeated by a special pol- 
len to which the victim is individually sus- 
ceptible. Many persons are susceptible 
to the action of more than one pollen. Pa- 
tients often suffer from rose-colds in 
early summer, and, again, in August, from 
the autumnal form of hay-fever. Of the 
198 cases collected by Beard the onset of 
the disease occurred — 

2 cases. 

6 
11 

8 

6 

6 

7 

7 
81 
54 

7 

1 case. 

2 cases. 



From May 1 to May 10, 


in 


U ^Q 




" 31, 




" June 1 




June 10, 




U IQ 




" 30, 




" July 1 




July 10, 




U ^Q 




" 20, 




" " 20 




" 31, 




'' Aug. 1 




Aug. 10, 




" 10 




" 20, 




'* " 20 




" 31, 




" Sept. 1 




Sept 10, 




CC IQ 




" 20, 




" " 20 




" 30, 
[48] 





WHAT HAY-FEVEE IS 

Of Bosworth's eighty cases the greatest 
mimber, fifty-one, occurred between Au- 
gust 10th and August 27th. The usual 
date assigned for the eonuneneement of 
paroxysms of hay-fever is the 29th of 
August. This form of the disease, com- 
mencing in the latter part of August, is 
designated as autumnal catarrh. 

Many patients have asserted that they 
are attacked annually on exactly the same 
date, and even the same time of day, each 
year. There can be little doubt that the 
psychic influence or peculiar mental an- 
ticipation may have a great deal to do 
with this circumstance. An attack may 
be brought on by the influence of the im- 
agination. Phoebus gives the history of 
a case in which attacks of sneezing were 
brought on "while looking at a beautiful 
picture of a hay-field." The well-known 
instance of J. N. Mackenzie, in which an 

[49] 



HAY-FEVER 

attack of hay-fever was brougM on in a 
susceptible individual subject to rose-cold 
by means of an artificial rose may be 
explained on this ground. Bosworth con- 
siders that the time of occurrence is 
influenced by psychic causes, and is an- 
alogous to the recurrence of chills in 
intermittent fever, and considers that 
deception as to the actual time of occur- 
rence might be proved in hay-fever as in 
intermittent fever, in which changing the 
hands of the clock may lead to a change 
in the regular recurrence of the chills. 
Prince gives the history of a case in which 
a hay-fever subject under the influence of 
auto-suggestion, by means of writing fre- 
quently on paper and thinking, day and 
night, in leisure moments, and of slight 
hypnotism, prevented the premonitory 
symptoms of hay-fever, and she was free 
from the annual attacks for several years, 

[50] 



WHAT HAY-FEVER IS 

when they recurred and continned yearly 
thereafter. Prince asks, may it not be 
that the reason why certain places, snch 
as Dublin, for instance, are reputed to 
have a specific influence against attacks, 
is the counter-suggestion thereby given 
that the patient will be free from attacks 
at such places? 

Pirrie states that it is next to impos- 
sible to definitely decide the duration of 
hay-fever attacks, as seasons, age, tem- 
perament, locality, treatment, and other 
circumstances tend to cause variations in 
different years and in different individ- 
uals. Treatment will do much to curtail 
the duration of the more prominent and 
distressing symptoms, but if left to them- 
selves it is seldom they depart under 
three or four weeks. A writer in the 
** Twentieth Century Practice of Medi- 
cine" estimates the duration as from four 

[51] 



HAY-FEVER 

to six weeks, according to the patient's 
surroundings and the atmospheric condi- 
tions. Asthmatic attacks may last from 
a few honrs to three days and disappear 
suddenly. Morell Mackenzie states that 
attacks last from a few hours to several 
days, or even longer, finally ceasing al- 
most as suddenly as they came, and leav- 
ing no trace either in local lesions or in 
systemic disturbance. Bosworth gives 
eighty cases, showing the durations of the 
annual attacks as follows: 

1 to frost 1 case. 

May 25, to July 1 3 cases. 

Aug. 1 1 case. 

July 1 2 cases. 

" 14 lease. 

frost 5 cases. 

July 4 4 " 

" 26 5 " 

Sept. 1 1 case. 

Aug. 1 1 " 

Sept. 1 1 " 

frost 4 cases. 

Aug. 27, to frost 51 " 

[52] 



From May 1 




'' 15 




" 10 




* June 1 




u ^ 




u I 




'^ 10 




" 10 




' July 1 




" 10 




" 10 




'' 25 




' Aug. 10 



WHAT HAY-FEVER IS 

All forms of hay-fever terminate with 
the first frost, and the long interval in 
which one may suffer is shown by the first 
case above from May 1st to cold weather. 
In the United States some who are at- 
tacked in May recover by the 1st of 
Jnly; some attacked in July are well by 
the 15th of August; some attacked in Au- 
gust recover by November 1st, while some 
unfortunates suffer throughout the period 
from May to November. The June type 
may be followed by a September visita- 
tion or become a permanent August at- 
tack, or the August type may disappear 
in certain individuals and reappear as a 

June cold. 

4. Symptoms 

Altho the affection is called hay- 
fever, there is seldom any degree of py- 
rexia, and, as a fever, it is not a decided 

one. There are two well-known types of 
53 ] 



HAY-FEVER 

the disease, — the catarrhal and the asth- 
matic. The onset of an attack is occa- 
sionally marked by feelings of general 
malaise, a loss of appetite, and depression 
of spirits. Indeed, these symptoms more 
or less characterize the entire course of 
the attack. A * Sickling in the roof of the 
mouth" one week before the onset was 
felt by a patient of Sajous. Another 
speaks of dull pains in the head and back 
two weeks before; chills and shuddering 
ten days before the attack is experienced 
by another, while a large proportion com- 
plain of palpebral pruritis from two to 
ten days before the onset of the nasal 
symptoms. It is only in those subjects 
whose hay-fever is of some years' stand- 
ing, Sajous points out, that the premoni- 
tory symptoms are present, and gives in 
evidence the testimony of a fellow-physi- 
cian, viz.: **My attacks for some years 

[54] 



WHAT HAY-FEVER IS 

past came with much regularity, about 
August 12th to August 14th. On these 
dates this year I arranged to be on the 
water, on Lake Ontario and the St. Law- 
rence Eiver, and entirely escaped every- 
thing like sneezing and irritation of the 
nose and eyes. StiU I had the usual hot 
and slightly irritable skin, then an erup- 
tion of urticaria, accompanied by dis- 
ordered stomach. This experience is pre- 
cisely the same as in 1880, except that 
then I was on the Atlantic." Macdonald, 
in 1893, had a patient whose earliest 
symptoms were a curious coldness and 
pallor of the nose even in warm weather. 
Li this connection it may be observed that 
in 1870 Roberts conceived the *' pathog- 
nomonic symptom" to be coldness of the 
tip of the nose. 

Beard divided the symptoms into local 
and constitutional. Among the latter he 

[55] 



HAY-FEVER 

regarded fever, loss of strength, the al- 
tered appetite and the nervous system, 
considering under this last, depression, 
indisposition to labor, sense of fulness and 
heaviness of the head, pain in the fore- 
head and behind the ears, partial deaf- 
ness, restlessness at night, inability to 
sleep, a sense of suffocation, and general 
irritability. For the local phenomena, he 
looked upon the skin, in the heart, chest, 
mouth and nose, eyes and ears. 

The periodicity of the attacks is a prom- 
inent symptom and is difficult to explain. 
Some peculiar psychic influence occasion- 
ally acts to precipitate an exacerbation. 
In no other way can we explain the cases 
of John N. Mackenzie and Morell Mac- 
kenzie already cited. Analogous to this 
remarkable periodicity are those cases of 
intermittent fever wherein each alternate 

day, at a given hour, the chill occurs. This 
[56] 



WHAT HAY-FEVER IS 

is generally true, moreover, not only of 
ourselves, but of the world around ns. As 
Holmes has beautifully shown in this con- 
nection, health and disease afford abun- 
dant illustration: The fixation of the 
number of heart-beats, of the respiratory 
movements, of the cycle of menstruation, 
or of the period of gestation are all recog- 
nizable in their unfailing occurrence, but 
their determination thereof, then, rather 
than at some other period, can not be ex- 
plained. So, in disease, are the muta- 
tions of the enteric temperature, the re- 
currence of the hectic, of the regularity 
of the return of the type of ague upon the 
second, third, or fourth days, or of hay- 
fever upon its annual date. We must 
recognize these phenomena as fixt, fur- 
ther we can not go. *'As the rhythm of 
physiologic effects is under the control 

of the central nerve ganglia, and as inter- 
[57] 



HAY-FEVER 

mittency is a peculiarly marked feature 
of so-called nervons disorders, so far the 
annual return and the variations are 
evidences of the neurotic origin of hay- 
fever." 

The onset of an attack of hay-fever be- 
gins with a sense of irritation referred 
to the upper nasal chambers, a sense of 
fulness or tightness across the bridge of 
the nose. There is an itching or burning 
sensation of the inner canthus of one or 
both eyes, which may be accompanied by 
convulsive movements of the eyelid, an 
itching or tingling in the roof of the 
mouth. Spasmodic sneezing soon occurs, 
and pain in the eyeballs and in the fron- 
tal regions develops. The paroxysms are 
more or less violent and prolonged. Ar- 
nold tells of sneezing in a patient for 
twenty-five times in close succession, forc- 
ing the pulse at the height of the attack 

[58] 



WHAT HAY-FEVER IS 

to one hundred and twenty beats to the 
minnte. These paroxysms are followed 
by an abundant, thin, serous discharge 
from the nose. The mucous membrane 
of the nasal fossae swells so as to block 
up the nasal passages, and respiration 
through the nares becomes impossible. 
The escape of serum from the nostrils 
seems to increase the intense irritation 
and makes the sneezing worse. The dis- 
charge from both eyes and nose gradually 
grows thicker and may become semipuru- 
lent. There is often a certain amount of 
painful vision, and sometimes swelling, 
besides the usual pricking and stinging of 
the conjunctival surfaces. There are fre- 
quent transient paroxysms of lacrimation, 
and there is often much swelling of the 
eyelids as well as of the conjunctiva. The 
face becomes puffy and edematous, and 
the senses of taste and smell become im- 

[59] 



HAY-FEVER 

paired. The pharynx, mouth, and tonsils 
share in the engorgement and become red, 
and simultaneously the inflammation of 
the eyes, nose, and throat becomes intense 
and painful. Swallowing may become so 
difficult that there is little rest night or 
day. Insomnia is common and is often 
attended by nervousness and a sense of 
suffocation out of all proportion to the 
gravity of the condition. Cough is not a 
constant feature, but in a considerable 
proportion of cases it comes on in the sec- 
ond week, and lasts through the attack. 
Generally it is spasmodic and so incessant 
at night that sleep is impossible, and there 
are soreness and pain resulting from the 
straining of the diaphragm and intercos- 
tal muscles. Bronchitis does not usually 
result, and expectoration is absent or 
scanty until late. Cough may continue 
after all other symptoms have ceased. 

[60] 



WHAT HAY-FEVER IS 

The pulse and temperature are not gen- 
erally altered, but later in the attack the 
temperature may be raised two or three 
degrees, doubtless from disturbed rest. 
A **su:fferer" records that, in some, the 
genito-urinary and rectal passages give 
the first warning by intense itching and 
burning. In one instance, a more than 
generally severe paroxysm induced rup- 
ture of the capillaries in the lacrimal ca- 
runcle of the right eye, causing engorge- 
ment of the organ and displacement of 
the visual axis, with consequent double 
vision for some days. The direct and re- 
flex changes in the vocal apparatus vary 
from loss of timber and harshness to 
complete inability to utter nasal vowels 
and consonants. 

The disorder varies much in intensity 
even in the same person within short in- 
tervals of time, so as to almost give 

[61] 



HAY-FEVER 

an intermittent character to the com- 
plaint. 

The attack finally ceases almost as sud- 
denly as it came on, leaving no trace of 
local lesion or systemic disturbance. It is 
accompanied in some patients with nettle- 
rash. Asthma is a late symptom, coming 
on after the acute symptoms have abated, 
and cough has existed for some time. It 
may appear at the height of the attack. 
It is more common in antmnnal catarrh 
than in the early forms. Its period, as a 
rule, begins at the fourth week, and it 
does not vary from ordinary asthma. It 
is sometimes periodic, occurring at the 
same hour night after night. Paroxysms 
appear associated with antecedent bron- 
chial rather than nasal symptoms. Nasal 
reflex phenomena, without cough, may oc- 
casion paroxysms. Persistent cough more 
usually exists in the intervals between 

[62] 



WHAT HAY-FEVER IS 

paroxysms. Beard says that four-fifths 
of the sufferers have congh or asthma. 
The symptoms are not nsually of equal 
severity each year. Asthma generally 
comes on in the daytime, a little ropy mu- 
cus being expectorated, and later an abun- 
dant frothy secretion. There may be only 
a slight remission, the dyspnea continu- 
ing so long as exposure continues. The 
attacks rarely produce emphysema of the 
lung, and sooner or later recovery ensues. 
Bosworth estimates that the asthmatic at- 
tacks come on earlier each year in those 
who have suffered from hay-fever in con- 
nection with asthma, and he believes that 
an attack of hay-fever is especially liable 
to develop an attack of bronchial asthma 
as a natural consequence of the disturb- 
ance in the nasal chambers. He also 
observed a number of cases in which hay- 
fever symptoms gradually abated while 

[63] 



HAY-FEVER 

the asthma became a prominent factor, 
and, again, that victims of hay-asthma 
finally acquired the perennial form of the 
disease, — the attacks occurring at all 
seasons without reference to the presence 
of pollen in the air. 

As already evidenced in Sajous' case, 
in a number of cases the attacks are pre- 
ceded by cutaneous eruptions. Laflaive 
cites cases with urticaria and eczema pre- 
ceding the onset of hay-fever. Facial pru- 
ritis and herpetiform eruptions are oc- 
casionally seen. J. N. Mackenzie speaks 
of an inflammation of the external audi- 
tory meatus in all respects analogous to 
that of the nose in hay-fever, occurring 
repeatedly in a lady during the summer 
months. 

Besides asthma, already mentioned, 
there is little tendency to permanent ill- 
efPects except thickening of the nasal mu- 

[ 64] 



WHAT HAY-FEVER IS 

cons membrane from the prolonged irri- 
tation. Taste and smell may be impaired 
during and for a long time after the at- 
tack. General irritability and nervous- 
ness may be more or less persistent. El- 
derly sufferers for a long time may have 
weakened hearts which intermit during 
attacks, which may recover with return- 
ing health or result in cardiac dilatation. 
Wyman mentions pneumonia in three 
cases during attacks. In one case the ca- 
tarrh ceased for two weeks to return after 
the pneumonia disappeared, when asthma 
also came on for the first time. 

5. Its Pathology^ Diagnosis and 
Prognosis 

Morell Mackenzie states that hay-fever, 
leaving no permanent structural lesion be- 
hind it, can not, therefore, be strictly said 
to have any pathology. Surely it is that 

[65] 



HAY-FEVER 

no distinct specific organisms have been 
found. Sajons calls attention to the dis- 
tinct physiologic functions of the two re- 
gions of the nasal cavities, the olfactory 
and the respiratory. The filaments of the 
olfactory nerve cover the superior tur- 
binated bones, and the upper third of the 
middle turbinated bones, and the corre- 
sponding portion of the septum. Thus 
the upper portions of the nasal cavities 
are devoted to the sense of smell and do 
not enter into the pathology of hay-fever. 
The respiratory portion of the nose in- 
cludes all the surfaces below the olfac- 
tory. It is under the control of the vaso- 
motor nerves of the sympathetic system, 
and is quite sensitive to local or periph- 
eral irritation. This sensitiveness resides 
in the terminal filaments of the sen- 
sory nerves, distributed over the surfaces 
of the mucous membranes. The mem- 

[66] 



WHAT HAY-FEVER IS 

branes of the posterior areas of the nasal 
fosssB are supplied with several branches 
of the sphenopalatine ganglion, which en- 
ter by the sphenopalatine foramen. This 
ganglion possesses a sympathetic root de- 
rived from the carotid plexus through the 
vidian nerve, thus establishing a connect- 
ing link between the nasal mucous mem- 
brane and the sympathetic system. 

In health the nasal mucous membrane 
pours out from twelve to sixteen ounces 
of watery serum daily, which — that it may 
warm, moisten, and cleanse the inspired 
air on its passage to the lungs — is dif- 
fused over the convex surfaces of the tur- 
binated bones. The centers in the medulla, 
through the vasomotor, control and regu- 
late this process of serous exudation; the 
nicety of which regulation is seen in the 
adjustment thereof to the varying hygro- 
scopic and thermic conditions of the air. 

[67] 



HAY-FEVEE 

The experiments of John N. Mackenzie, 
in 1884, showed: 

1. That in the nose there exists a well- 
defined sensitive area whose stimulation, 
through a local pathologic process or 
through an extra irritation, is capable of 
producing an excitation which finds its 
expression in a reflex act, or in a series of 
reflected phenomena. 

2. That this sensitive area corresponds, 
in all probability, with that portion of the 
nasal mucous membrane covering the tur- 
binated corpora cavernosa and the most 
sensitive spots covering the posterior end 
of the inferior turbinated body and the 
septum immediately opposite. 

3. That nasal cough is caused only by 
stimulation of this area. 

4. That the tendency to evolution of 
reflex phenomena varies in different indi- 
viduals, and is probably dependent upon 

[68] 



WHAT HAY-FEVER IS 

the varying degree of excitability of the 
erectile tissue. 

These sensitive areas correspond to 
the distribution of the sphenopalatine 
branches of the superior maxillary nerve, 
as distinguished from the nasal branch of 
the ophthalmic, which latter supplies the 
more anterior portions of the nasal fos- 
sae. The former nerves, derived through 
the ganglion of Meckel, therefore, prob- 
ably contain the vasomotor nerves which 
govern the erection of the turbinated 
tissue, and, hence, the localization of 
the sensitive areas becomes the key to the 
mechanism of the paroxysms. Neverthe- 
less, Beard was inclined to transfer 
the point of greatest excitability from the 
peripheral ends of the nerve-filaments to 
the nerve-centers themselves, because it 
seems a more comprehensive explanation 
of the varied phases of the disease. 

[69] 



HAY-FEVER 

Roe explained that the more frequent 
occnrrenee of asthmatic paroxysms at 
night might be brought about by the 
gravitation of blood to, or the contact of 
polypi upon, these sensitive areas. Sajous 
thought it was evident that there were 
three areas capable of producing reflex 
symptoms in the course of a paroxysm of 
hay-fever, and that the three combined 
formed the key to the local nervous ele- 
ment, not that the three areas must take 
part, but in some, one of them, in others, 
two of them, etc. In the asthmatic cases, 
he noticed that both anterior and pos- 
terior areas were sensitive, the latter 
especially so. 

Capp pointed out two distinct spots or 
areas of the mucous membrane of the 
nasal cavities, one at the posterior and 
one at the anterior extremity of the in- 
ferior turbinates, one or both of which 

[70] 



WHAT HAY-FEVER IS 

may be supersensitive in individual cases ; 
also a spot in the anterior nasal chambers 
at the upper angle formed by the septum. 
All these are exquisitely sensitive, and, 
when irritated, produce extensive reflex 
symptoms. Trouble appears to begin at 
one or all of the points, while the rest of 
the Schneiderian membrane is in normal 
condition; but with sneezing, hyperemia 
and hyperesthesia ensue, and, through 
continuity, may extend to throat, ears, 
and eyes. 

In speaking of the three reflex areas. 
Holmes said that it is regarded that all 
points of the cavernous tissue are not 
equally susceptible to irritation; the sen- 
sitive areas are the inferior turbinates 
(the posterior and middle reflex areas) 
and the portion of the septum immedi- 
ately opposite, being particularly related 
to cough and asthma; the anterior, in the 

[71] 



HAY-FEVER 

vestibule, to sneezing, lacrimation, and 
other catarrhal symptoms. "We might 
compare these reflexes with certain other 
cases of reflex asthma (not hay-fever) 
benefited by removal of the tonsils. 

Bosworth regarded the continuous 
sneezing as pathognomonic and holds that 
the hyperemia is *^ confined entirely to the 
large venous sinuses, the capillaries 
proper not being congested," and speaks 
of the watery, serous discharge with the 
bluish-gray '* tinge of the mucosa verging 
on opalescence, the surface of the mem- 
brane being covered with slightly viscid, 
watery serum, which gives it a glassy, 
semitranslucent aspect." 

During an attack of hay-fever the erec- 
tile tissues of the nasal passages and the 
posterior throat become distended, the 
blood-vessels are engorged, groups of 
lymph-cells fill the lymphatic spaces, the 

[72] 



WHAT HAY-FEVER IS 

mucous surface is crowded with migrat- 
ing leucocytes (white blood-corpuscles), 
younger epithelial cells are vacuolating 
and proliferating, secretion is increased 
in quantity and altered in character and 
composition, sensation is heightened, in- 
tensified, altered, or benumbed, and the 
whole metabolism of the affected region 
is profoundly disordered. Examination of 
the lower borders of the turbinated bones 
will disclose the mucous membranes of 
the nasal cavities arranged in thick, loose 
folds, owing to the peculiar distribution 
of the network of arteries and veins which 
go to make up *' cavernous tissue." It is 
peculiar to this tissue that it may suddenly 
be engorged with blood, extremely dis- 
tending it, and as suddenly emptied and 
the engorgement relieved. It is especially 
thick over the inferior turbinated bones 
and over the lower and posterior part of 

[73] 



HAY-FEVER 

the nasal septum, and also upon the lower 
edge of the middle turbinated bone. In 
acnte conditions the engorgement and dis- 
tention soon subside. In chronic states the 
mucous membrane becomes markedly thick- 
ened and the blood-vessels enlarged and 
tortuous. The subsidence of the engorge- 
ment can not occur, and as a result there 
is a greater or less degree of closure of the 
nasal passages. 

The mucous membrane of the nasal cav- 
ities in hay-fever does not present the 
characteristic features of an acute inflam- 
mation. The impact of pollen or exciting 
irritant causes complete relaxation of the 
large veins of the turbinated bodies and 
an exudation of serum, which relaxation 
continues so long as pollen or the irritant 
is in situ, but as soon as it is removed the 
normal caliber is again restored and the 
attack subsides. Deviations of the sep- 

[74] 



WHAT HAY-FEVER IS 

turn or clironic rhinitis are occasionally 
found concurrent with the disease, but 
can not be regarded as characteristic. 

Hay-fever may be distinguished from 
asthma, common catarrh, bronchitis, acute 
rhinitis, remittent fever, and catarrhal 
conjunctivitis. The salient feature of 
hay-fever is its periodicity or annual re- 
currence. This is part of its very nature, 
is the central point of diagnosis, is its 
chief characteristic, and to its elucida- 
tion, Holmes says, all existing theories 
tend. 

Beard states that hay-fever is like 
asthma in the following points : 

1. It is hereditary; 

2. It is more or less periodic; 

3. It is paroxysmal; 

4. It is correlated to other functional 
nervous affections; 

5. The paroxysms are excited by a great 

[75 J 



HAY-FEVER 

variety of irritants ; persons being differ- 
ently affected; 

6. It is singularly obstinate and is re- 
lieved by tlie same remedies. 

Bosworth considers bay-fever depen« 
dent upon: 

1. A nenrotic babit; 

2. Pollen in tbe atmosphere; 

3. A disordered condition of tbe nasal 
passages. 

Wbile asthma is dependent upon : 

1. A general neurotic condition; 

2. Obscure conditions of tbe atmos- 
phere ; 

3. Diseased bronchial (not nasal) mu 
cons membranes. 

It is the comparative suddenness of the 
onset, as well as its sudden departure, the 
violent paroxysms of sneezing, and the 
character of the nasal discharges which 
are the peculiar features of hay-fever* 

[76] 



WHAT HAY-FEVER IS 

The first attacks are likely to be mistaken 
for ordinary coryza, but here the abrupt 
onset, the characteristic edematous puf- 
finess of the eyelids, the absence of con- 
stitutional symptoms will indicate the 
difference. In children, moreover, at- 
tacks of hay-fever are most liable to be 
mistaken for acute colds or rhinitis, — ^but 
here, again, the above points may serve to 
distinguish, together with the sequence of 
the symptoms, the time of year, and the 
physical signs of an acute bronchitis, if 
it extends so far. The approach of cold 
weather and the coincident departure of 
the symptoms will make clear a diagno- 
sis, while the history of previous attacks 
at the season of the year most favorable 
to hay-fever, the presence of certain irri- 
tants, and the general condition of the 
bodily symptoms may be of aid in dis- 
tinguishing the affection. In acute rhi- 

[77] 



HAY-FEVER 

nitis there are several stages, viz.: First, 
a dry stage, lasting for a few, say twelve, 
hours; second, a serous discharge lasting 
two or three days; and, third, a mnco- 
pnrnlent discharge for from three to five 
days, — ^while the entire attack runs its 
course in from five to ten days if no com- 
plications ensue. In hay-fever there is 
no dry stage; the discharge from the out- 
set is purely serous and never muco- 
purulent during the entire course. The 
nasal discharge in hay-fever is sometimes 
slightly opaque, and it may contain some 
few epithelial cells and viscid mucus. In 
acute rhinitis examination of the nares 
will show an inflammatory area while hay- 
fever shows none. Hay-fever is a vaso- 
motor paresis, and is easily diagnosed 
from inflammatory coryza by the swollen 
bluish-gray appearance of the inferior 
turbinated bones, and by the fact that the 

[78] 



WHAT HAY-FEVER IS 

first train of symptoms continues through 
to the end. Examination of the nares will 
disclose occlusion dne to the swollen tur- 
binated bones lying in contact with the 
septum. The appearance of the mucous 
membrane itself is characteristic and only 
slightly resembles an inflammatory pro- 
cess. It is markedly swollen, not bright 
red as in rhinitis, but bluish-gray, cov- 
ered with a thin, slightly viscid, watery 
serum, giving it a glassy, semitranslu- 
cent, at times opalescent appearance. 
Again, the marked puffiness of the eye- 
lids, the great suffusion of the eyes, the 
photophobia, and even epiphora are dis- 
tinguishing features of hay-fever. 

The sensitive areas spoken of, particu- 
larly those on the lower and posterior 
parts of the septum and the inferior tur- 
binated bones, are of value in differen- 
tiating hay-fever, and the markedly pro- 
[79 ] 



HAY-FEVER 

nonnced paroxysms of sneezing are very 
prominent in hay-fever. 

People are subject in the changeable 
climate of spring and early summer to 
catch colds, and especially is this true of 
those prone to catarrh. These cases are 
sometimes mistaken for hay-fever. The 
readiness, however, with which they yield 
to anti-catarrhal treatment shows their 
nature. 

The prognosis is invariably good as to 
life. Sufferers often live to advanced 
ages. Hay-fever is no bar to life-insur- 
ance, but unless rationally treated the 
chances of permanent cure are very small. 
There are few exceptions to the rule that 
the tendency is, when once established, to 
an annual recurrence, unless the predis- 
posing causes are removed, or there is 
removal of or away from the exciting 
cause. Beard states that hay-fever has 

[80] 



WHAT HAY-FEVER IS 

no effect on longevity, and that, judging 
from observation and analogy, this afflic- 
tion may act as a kind of safety-valve for 
the nervous diathesis, preventing other 
and more serious disorders, and thus be- 
coming the friend rather than the enemy 
of life. When once attacked, unless 
properly treated, escape is rare in any 
subsequent year. Even changes in consti- 
tution in extreme age are no bar or pro- 
tection. It rarely skips a year, provided 
locality and influence are the same. Ab- 
solute immunity is only obtainable at the 
price of temporary exile. There is no 
proof that hay-fever is generally milder 
or severer in certain years all over the 
world or over a country, yet evidence is 
satisfactory that in certain localities it 
varies greatly in different years. 

Now and then, but not often, the ten- 
dency to the disease seems to be out- 

[81 ] 



HAY-FEVER 

grown. In one of Beard's cases the dis- 
ease skipped two years. Dr. Gibbons, of 
California, mentions a terrible case in 
which the attacks in successive years be- 
came lighter and lighter and finally dis- 
appeared entirely. 

With respect to increase or decrease 
of severity of symptoms with advancing 
years there is no constant law. In some 
cases the disease grows milder, in others 
severer, in others still, years of compara- 
tive mildness alternate with years of com- 
parative severity. The early form may 
change into the later form. There is no 
doubt, however, that attacks may change 
from the early to the late form, and vice 
versa, and in advancing years may be 
milder. Bosworth states that the younger 
the patient the better is the promise of 
relief; and that rose-cold, belonging more 
especially to early life, is to be regarded 

[82] 



WHAT HAY-FEVER IS 

more favorably than other forms. Mac- 
donald has observed spontaneous disap- 
pearance in children, perhaps due to an 
increase, pari passu with growth and de- 
velopment of nervous stability. 

As regards the termination of each in- 
dividual attack the prognosis is invari- 
ably favorable; cessante causa, cessat 
effectus. There is almost equal certainty 
that with the same causative influences 
the attacks will reappear upon exposure 
to the exciting cause. It is peculiar, too, 
that the disease of one year's standing 
has proved as obstinate as one of from 
twenty to thirty years' duration. In 
these instances it may be a question as to 
how firmly fixt has become the neurotic 
habit. 

W. W. Bulette, of Colorado, in 1896, as 
a result of his own experience, made the 
assertion that more than eighty per cent. 

[ 83] 



HAY-FEVER 

of hay-fever su:fferers can be permanently 
and effectually cured. Thoro examina- 
tion of the patient and elimination of 
every possible source of irritation and 
pathologic condition are necessary. 

I desire to be more emphatic, and from 
my results in the treatment of over 200 
cases during the last twenty years, I be- 
lieve that the curability of the disease 
can not be questioned. That all cases can 
be cured is questionable; but we can un- 
hesitatingly say that a majority of cases 
are curahle, and that positive relief , with- 
out change of residence or inconvenience, 
can he afforded during the period of oc- 
currence, if treatment is directed along 
the lines laid down in the following 
chapter. 



[84] 



PART II 
ACCEPTED CAUSES 



[85] 



PART II 

ACCEPTED CAUSES 

1. When Due to Some Exciting Agent 
Such as Pollen 

It being generally recognized that there 
are two elements entering into the causa- 
tion of hay-fever, viz., an exciting agent 
and a predisposing or preexisting, con- 
dition, regard will be given the subject 
of cansation from this standpoint. 

A great number of agencies have been 
regarded as the direct causes of this 
disease, but opinion in the main has as- 
signed pollen as the essential factor, act- 
ing upon the preexisting condition or 
predisposition. It may be better, however, 
to give a resume of other agencies before 

[87] 



HAY-FEVER 

regarding this subject of pollen. The 
most important of these are heat, light, 
dust, ozone, overexertion, ipecac, lyco- 
podimn, comnarin, benzoic acid, choco- 
late, or several of these in combination. 

No attempt to signify or designate a 
definite canse was made by the early 
writers until 1819, when Bo stock first 
described the malady and ventured the 
view that it was due to the influence of 
solar heat. He attributed his own pro- 
longed sufferings to the exposure to the 
sun's rays and fatigue. 

Some time after, Phoebus attributed the 
affection to **the first heat of summer," 
which, he stated, ^4s a stronger cause 
than all the grass emanations put to- 
gether.'' Phoebus subsequently modified 
his views so as to regard the first heat of 
summer as acting only in an indirect man- 
ner as an exciting cause, and admitted 

[88 1 



ACCEPTED CAUSES 

that hay and the blossoms of rye caused 
exacerbations. It can not be contended, 
at this day, that heat alone will provoke 
the disease. In the plains of India when 
the heat is greatest it is not found, al- 
tho later in the year, in the cooler 
months and before vegetation is burned 
up, it does appear; but among the hills 
of India, where the climate is milder and 
the grasses and cereals are in blossom, 
hay-fever exists. At sea, when vessels 
are becalmed and heat is most intense, and 
in the great heat of the desert hay-fever 
is not found. Pirrie shows that great 
heat is common to all cases, even when 
the vegetable world is looked to for the 
cause, and strangely points out that the 
premonitory feelings of an attack coin- 
cide with those caused by high tempera- 
ture. One of the most interesting cases 
from this standpoint is that of an En- 

[89] 



HAY-FEVER 

glishman, who, altho not a medical 
man, was well known to science — Richard 
Proctor. The asthma — for it took this 
form — occurred only during the cold 
months, and was always aggravated by a 
rime or hoar-frost, especially if the lat- 
ter was followed by a bright, sunny day. 
It is a striking fact that in regions com- 
paratively free from the disease persons 
subject to it become worse on warm days, 
or when the wind blows from the south. 
It has been found by experience that 
while this aggravation by winds is in 
most part due to the presence of more 
pollen, the higher temperature is also in 
a measure responsible. Hot, dry days are 
more favorable to the dissemination of 
pollen than rainy ones, and it becomes 
especially active when hot, dry periods 
follow stormy weather. In the light of 
Blackley's experiments upon the amoxmt 

[90] 



ACCEPTED CAUSES 

of pollen in the atmosphere, these facts 
would seem to explain the action of heat 
and sunlight as an active cause in the pro- 
duction of the exacerbations of hay-fever. 
Phoebus was dissatisfied with the view 
of the influence of solar heat, and thought 
that the longer days, which produce a 
more continuous action of light, were per- 
haps to blame; but where light is strong- 
est and lasts the longest — ^indeed, in the 
land of the ''midnight sun'' — ^hay-fever 
is practically unknown. Pirrie called at- 
tention to the fact that exposure to strong 
light aggravated the symptoms of the 
attack. The cited case of the late Eichard 
Proctor is an example of the truth of this. 
There is an instance of the widow of a 
clergyman whose attacks, most severe in 
summer, were aroused by sunlight in the 
early morning. Ingals knew a clergy- 
man who was unable to cross the street 

[91] 



HAY-FEVER 

on a hot day without sneezing violently 
unless he carried an umbrella. Persons 
with sensitive mucous membranes, espe- 
cially subjects of hay-fever, are, no doubt, 
sometimes liable to attacks of sneezing 
from sunlight; but these symptoms must 
not be mistaken for true hay-fever. In- 
gals states that he knew an individual in 
whom attacks of sneezing were brought 
on by exposure to bright gaslight. Gas- 
light was also regarded by Beard as a 
cause of this affection. However, Morell 
Mackenzie shows that gaslight is em- 
ployed more in winter when the affection 
does not prevail than in the English 
spring and American autumn, when the 
affection most prevails. Nothing can ex- 
ceed the reflected glare of sunlight at sea 
on a bright day, yet it is upon the sea 
that exemption from attacks of hay- 
fever is universally found. 

[92] 



ACCEPTED CAUSES 

From Ms scientific investigations upon 
the subject, Beard, whose published work 
is a model, concluded that it was ex- 
tremely probable that dust occasionally 
caused hay-fever. Out of 198 cases of 
hay-fever reported by him no less than 
104 attributed the affection to dust. One 
hundred and forty-two of these cases, how- 
ever, occurred between May and Septem- 
ber, the usual hay-fever season; and the 
lay, not the trained professional, mind 
advanced the causes. Some attributed the 
affection to * indoor dust"; some to ** cin- 
ders.'' These data of Beard, therefore, 
must be taken cum grano sails. More 
especially is this so since a paroxysm of 
sneezing and subsequent coryza, fre- 
quently brought on in normal health by 
the mechanical irritation of dust or even 
strong odors, should hardly be dignified 
as an attack of hay-fever. In England, 

[93] 



HAY-FEVER 

in February, March, and April, when 
strong east winds often blow clouds of 
dust against the face, the symptoms of 
hay-fever do not appear, whereas in June 
and July, when dust is comparatively lit- 
tle, the affliction is most extant. 

Holmes stated that even in winter-time 
stirring among old books or in an old 
garret the exposure to the fine dust there- 
from would, by simple mechanical irri- 
tation, produce an attack in him. It has 
been the consideration that dust, or pol- 
len, acting as any other form of dust, 
could be kept from entering the nasal 
chambers that has given rise to the va- 
rious inventions to purify the air before it 
enters the nose, such as plugs of cotton or 
wool, and veils (which, in addition, soften 
the glare of the sun and lessen the irritating 
action of winds. Every hay-fever suif erer 
knows the little value of such a device. 

[94] 



ACCEPTED CAUSES 

From the vast quantity of facts and ob- 
servations gathered together by him, 
Phoebus, who previously had ascribed sun- 
light as the cause of hay-fever, endeav- 
ored to extract a complete theory of the 
disease. He suggested an excess of ozone 
in the atmosphere as a possible cause. It 
remained, however, for Blackley, in 1873, 
by his great endeavors and scientific 
methods of investigation, to disclose the 
fallacy of this theory. He purposely 
breathed air highly charged with ozone 
for five or six hours without effect; and 
without inconvenience he inhaled ozone 
artificially prepared and in quantities 
far exceeding that found in the same vol- 
ume of atmospheric air. This same phy- 
sician also studied upon himself the ef- 
fects of benzoic acid, a substance shown 
by Vogel to be contained in Anthoxan- 
tJium odoratum and Holcus odoratus, the 

[95] 



HAY-FEVER 

two species of flowering grasses to which 
the causation of hay-fever has been at- 
tributed. Likewise he investigated the 
odorous principle of many flowering 
grasses, conmarin, and the volatile oils 
which impart to many plants, such as 
peppermint, juniper, rosemary, and lav- 
ender, their characteristic perfume. In 
all these cases the results were negative. 
Various other exciting causes are in 
numberless variety and many of purely 
idiosyncratic nature. Emanations from 
dry hay, sunlight, gaslight, heat, minute 
organisms as supposed by Helmholtz, the 
*' mange" insect, dusts of all kinds, bad 
air, railway smoke, brimstone matches, 
flowers and fruits, odors from dogs, cats, 
horses, cattle, rabbits, guinea-pigs, and 
wild animals, have all been held respon- 
sible for the paroxysms. Ward Smith 
records linseed meal and mustard as 

[96] 



ACCEPTED CAUSES 

exciting causes. Wm. Murrell mentions 
powdered May-apple (podophyllum), the 
effluvia of clean pocket handkerchiefs 
fresh from an ironing table, locust-tree 
blossoms, mulberry blossoms, and fruit. 
The exhalations from feathers have been 
regarded as causes. It is well-known that 
various drugs like ipecacuanha and lyco- 
podium give rise to attacks, and sulfur 
has been mentioned as a cause. Sir 
Thomas "Watson names a servant in St. 
Bartholomew's Hospital affected by ipe- 
cac. CuUen tells of an apothecary's wife 
who, whenever ipecac was triturated in 
the shop, had an attack of hay-fever. He 
also mentions the vicinity of a rice- 
threshing floor as a provocative cause. 
Itzigson tells of a merchant who had hay- 
fever paroxysms whenever fresh coffee 
was handled in his presence ; and it is re- 
corded of a dyer that he could not work 

[97] 



HAY-FEVER 

when the wood of the oak {Quercus tine- 
toria) was lying about. The author 
knows of a case in a physician in whom 
violent paroxysms of sneezing are in- 
duced by the tasting of chocolate. It is 
related in the *^ Twentieth Century Prac- 
tise of Medicine" that a hay-fever pa- 
tient fond of tomatoes and watermelons 
was unable to eat of them during the 
usual hay-fever season without most vio- 
lent disturbance of the gastro-intestinal 
tract. Bastian was subject to attacks of 
an affection like hay-fever while dissect- 
ing the Ascaris megalocephala, a parasite 
infecting the horse. Hyde Salter tells of 
a clergyman affected by the vicinity to a 
dead hare, and who was thus able to de- 
tect the presence of a poacher. H. Charl- 
ton Bastian had like effects from the 
*^ mange" insect of the horse. Ringer 
and Murrell tell of a young gentleman 

[98] 



ACCEPTED CAUSES 

made worse by the vicinity of horses or 
stable people. Once, while in the theater, 
an attack suddenly supervened without 
any appreciable reason until a horse gal- 
loped upon the stage. Macdonald, in 1893, 
mentioned a patient who, two or three 
hours after having patted his horse with 
his gloved hand, inadvertently put it to 
his face, and was immediately seized with 
a violent paroxysm. The odor from the 
inner aspects of the legs of the horse was 
very irritating to one writer, a ** suf- 
ferer." Einger and Murrell cite the case 
of a gentleman who, subsequent to an 
acute pleurisy, was ever after a subject 
of ** hair-caterpillar asthma," and was 
immediately attacked if by any chance he 
touched a caterpillar. 

The difficulty of sometimes finding 
some exciting agent is shown by the ease 
of Drenger. After searching several 

[99] 



HAY-FEVER 

years in vain for the canse of at.acks of 
hay-fever cansed by entry into a certain 
room in a house, and after ransacking 
nearly everything in the house, a mattress 
was suspected, and, upon removal, was 
satisfactorily shown to be the offending 
agent. 

The odor of peaches, of violets, of the 
mignonette, of chocolate, of musk, and of 
peppermint, has come in for a share of the 
blame. Trosseau relates of himself that 
attacks came on when he entered a room 
in which there were violets. The botanist 
Broussais was often impeded in his work 
by attacks caused apparently by the odor 
of a rose. Hiinerswolff and Morell Mac- 
kenzie each cite a case in which the per- 
fume of the rose produced attacks of 
coryza. The former's account is in the 
'^Ephemerides,'' and has been often re- 
ferred to. The latter 's case proved rebel- 

[100 1 



ACCEPTED CAUSES 

lions to treatment, and the sufferer had, 
at last, to banish these flowers from her 
garden. That this peculiar antipathy to 
flowers is often imaginative is also shown 
by John N. Mackenzie, who cites the case 
of a subject of hay-fever to whom he 
handed an artificial rose. Immediately an 
attack of rose-cold ensued. A patient men- 
tioned by Phoebus and Morell Mackenzie, 
while gazing upon a picture of a hay field, 
was seized with an attack of hay-fever. 
These last two instances indicate the 
psychic influence rather than any extrane- 
ous cause, but they serve to show the 
varieties of exciting agents. 

The external cause which has been by 
far the most generally recognized and ac- 
cepted as the most frequent is pollen. The 
older writers upon this theory did not dis- 
tinguish the underlying condition neces- 
sary before pollen could act as a cause of 

[101] 



HAY-FEVER 

tlie disease. The remarkable and elabo- 
rate experiments of Blackley, from 1866 
to 1878, conclusively prove that a most 
important exciting canse of hay-fever is 
found in the action of pollen upon the 
mucous membrane of the nasal cavities. 
In his own person he showed that the in- 
halation of pollen always brought on the 
symptoms of hay-fever; that there was a 
direct relation between the intensity of 
the symptoms and the amount of pollen 
in the air, and that none of the other 
agents referred to, such as heat, light, 
ozone, dust, or odors, would, of themselves, 
cause the distress. His range of ob- 
servation included the pollens of various 
grasses and of cereals and of plants of 
thirty-five other natural orders. His ex- 
periments were made in the hay-fever sea- 
son in England, between the end of May 
and the latter part of July, and showed 

[102] 



ACCEPTED CAUSES 

that ninety-five per cent, of the pollen con- 
tained in the atmosphere belonged to the 
Graminacece. The apparatus from which 
he obtained the most satisfactory results 
in his investigations consisted of a verti- 
cal plate of glass, % ^^ ^^ '^^^^ ^ diam- 
eter. It was covered with a hood, and was 
pivoted to an upright staff. A weather- 
vane surmounted the hood to control the 
face of the glass-plate before the wind. 
Upon this glass-plate was affixt a micro- 
scopic cover-glass, one centimeter in di- 
ameter, covered with glycerin. Any pollen 
floating in the atmosphere would thus be 
carried upon the plate by the wind-current 
and adhere to the glycerin upon the glass- 
slide. Blackley thus found that the amount 
of pollen caught upon the plate increased 
progressively from the seventh to the thir- 
tieth of May, when twenty-five grains were 
counted, to seventy-six grains on the 

[103] 



HAY-FEVEE 

eiglitli of June, and to 280 grains on the 
tenth of June. On the twenty-eighth of 
Jnne 880 grains were counted, after which 
date they decreased until the first of Au- 
gust, when they had completely disap- 
peared. Bright, sunny days brought 
large quantities of pollen, while rainy days 
decreased the amount. Passing showers 
ameliorated the individual symptoms, tho 
not affecting the amount of pollen depos- 
ited upon the slide. Blackley also clearly 
showed that the mucous membranes of the 
nasal fossae were not affected by pollen in 
the atmosphere when twenty-five grains 
per diem only were deposited on his glass, 
while seventy-five grains in twenty-four 
hours would irritate in certain individuals. 
When 280 grains of pollen per day were 
deposited the direct action upon the mu- 
cous membrane of this quantity would 
result in complete vascular dilation. 

[104] 



ACCEPTED CAUSES 

Clinical observation has shown a paral- 
lel, but by no means a complete, analogy 
to the above phenomena in the action of 
cocain in different strengths of solution. 

Emanations from the rose and from rye 
have been shown to have caused coryza, 
occlusion of the nostrils, and sneezing for 
from six to eight hours. The sweet-scented 
vernal grass {AntJioxanthum odoratum), 
sweet-scented soft grass {Holcus odora- 
tus)y meadow grass, meadow fox-tail, 
Indian corn, barley, wheat, oats, bean- 
flowers, lilies, elder trees in bloom, the 
goldenrod, hay, timothy, and clover, and 
others may be mentioned. In America the 
pollen of the Eoman wormwood, ragweed, 
or hogweed {Ambrosia artemisicdfolia), 
is the most commonly referred to. It is 
very common in nearly all the States. It 
blossoms in August and September, the 
prevalent time of hay-fever. Wyman and 

[105] 



HAY-FEVER 

his son, who had fled to the White Moun- 
tains to avoid hay-fever, were immediately 
attacked when a package of the ragweed 
was opened there. The seashore, usually 
exempt, sometimes is not so, probably due 
to the presence there of the pollen of the 
Artemisia gallica, another kind of worm- 
wood. In England the Anfhoxanfhum odo- 
ratum, or ^'sweet-scented vernal grass," 
seems especially causative. There must 
also be mentioned the common daisy 
{Bellis perennis) of England; also the 
rye-grass {Lolium perenne) and '' sweet- 
scented soft grass'' {Holcus odoratus). 
In Germany the rye-blossom is chiefly in- 
dicated as a cause. In Australia the Cape 
weed pollen is regarded as most com- 
monly provocative. It covers the hills 
round about Adelaide to the height of 
some thousand feet or so. Most of the 
population of Adelaide is affected with 

[106 ] 



ACCEPTED CAUSES 

hay-fever during the time of its blossom- 
ing, viz., in September. In India, where 
the malady occurs chiefly in February, it 
is the blossoms of the mango-tree {Mangi- 
fera indica) that are held responsible. 

J. C. Wilson holds that most subjects are 
not sensitive to emanations from hay, and 
points out that there are no distinctive 
bacteria to give rise to the affection. 
Marsh, himself a suferer, stated his be- 
lief in the pollen theory, conceiving hay- 
fever analogous to Rhus toxicodendron, 
or ivy-poisoning of the skin. 

There are two authentic cases which 
would impair the pollen theory, the well- 
known exemption of hay-fever subjects at 
sea being granted. One is mentioned by 
Walshe, in which a passenger retained his 
symptoms of hay-fever during a passage 
across the Atlantic. Abbotts Smith has re- 
ported the other, in which the disease came 

[107] 



HAY-FEVER 

on at sea nine miles from land. In this lat- 
ter case, unfurling the sails in which a 
large quantity of pollen had been folded 
may explain the occurrence. In the former 
instance the diagnosis was by no means 
certain and the presence of some other ir- 
ritant may have accounted for the dis- 
tress. Moreover, it is by no means impos- 
sible for pollen to be deposited on a ship 
even when miles away from land. In 
speaking of the distribution of pollen Dar- 
win tells of how the ground near St. Louis, 
in Missouri, has been so widely covered 
with pollen that it looked as if it had been 
sprinkled with sulfur. Pine forests, 400 
miles south, were probably the place and 
distance from which it came. On March 
16, 1883, in Philadelphia, ignorant people 
took for brimstone a shower of yellow 
pollen which had been blown from some 
distant pine forest. 

[108] 



ACCEPTED CAUSES 

After citing many of the various causa- 
tive pollens Holmes says that he is ^*not 
aware that any specialized action has been 
proved; all act (if at all) by mechanical 
irritation.'' He also shows the punctu- 
ality of flowering on the selfsame date 
yearly is an absurdity, depending, as the 
flowers do, upon the variations of the 
seasons. 

The date of the flowering of plants 
varies within certain limits, and he points 
out the mutability of the blossoming date, 
or, more rationally, its limited variation, 
and further adds that *'even as a mere ir- 
ritant, as pollen affects comparatively few, 
it must act upon a condition which is pre- 
existent, which is, therefore, independent 
of and predominates it, else would the 
cause, pollen, produce it universally." 

As already mentioned, it has been 
claimed, that a toxin generated from pol- 

[109] 



HAY-FEVEE 

len by a fermentative process in an alka- 
line solution is the cause of hay-fever. 

2. The Predisposing Causes 

While millions of people are exposed to 
the exciting causes of hay-fever, compara- 
tively few suffer from it, and that there is 
an underl^dng condition, predisposition, 
or idiosyncrasy, can hardly be doubted. 
Exactly what this is, or on what it depends, 
is unkaown. Abbotts Smith, as early as 
1865, spoke of a predisposition to attacks 
of hay-fever as one of the principal causes 
thereof. As Holmes has shown, there must 
be individual predisposition, since the ex- 
citing causes, if pollens, are everywhere. 
This predisposition or idiosyncrasy has 
generally suddenly developed without ap- 
parent reason. It has been argued that it 
is systematic or central, and that it is due 
to some local abnormality of the mucous 

[110 1 



ACCEPTED CAUSES 

membrane, the capillaries, or the periph- 
ery of nerves. Once acquired, however, it 
is seldom lost, and it apparently increases 
with each successive year. 

The influence of race is seen in the fact 
that the English-speaking people are the 
principal sufferers. In India, Africa, and 
Australia it is mostly the English and 
Americans who are attacked. In America 
it occurs in nearly every State, altho much 
more infrequently in the South. In Can- 
ada hay-fever is rare, especially in the 
maritime provinces. Wyman relates a 
case — the only one reported— of hay-fever 
in an Indian child. Beard mentions that 
Dr. Jacobi, of New York, who practised 
much among the Germans, had never met 
with a case in that nationality ; and in the 
same city a similar observation was re- 
corded by Dr. Chaveau, a practitioner 
among the French. Sajous has called at- 
[111 J 



HAY-FEVER 

tention to a curious fact in this connec- 
tion — viz., that the principal sufferers, 
American and English, are excessive tea- 
drinking nations, and that this beverage 
may exert a depressing influence on nerve- 
centers. It would be interesting to have 
some information as to the existence of 
hay-fever in China and Japan, the tea- 
producing countries. John N. Mackenzie, 
in 1884, gives the first recorded instance 
of hay-fever in a negro, a male of thirty- 
five, tall, well-proportioned, and respect- 
able, the attack lasting from the second 
week in August to late in September. A 
sensitive spot was found on the left in- 
ferior turbinated bone, 1^/4 inches within 
the nostril, which gave origin to a most in- 
tense paroxysm of asthma on simple con- 
tact with the probe. 

Eeports of hay-fever have come from 
nearly every quarter of the civilized globe. 

[112] 



ACCEPTED CAUSES 

It is seldom seen in the far North, and is 
more frequent in the temperate than in the 
torrid zone. It is seen more often in urban 
than in rural districts. The disease is by 
far the most frequent in Great Britain and 
the United States. In Norway, Sweden, 
and Denmark it is seldom found, and it is 
scarcely ever seen among the natives of 
Eussia, Germany, France, Italy, or Spain. 
The English and Americans in India and 
Africa are the only ones who are affected 
by it. Macdonald, in 1893, said the Irish 
are certainly not exempt. In the north of 
Scotland it is very infrequent, while in the 
south of England the disease is more fre- 
quently found than in the north. In Aus- 
tralia and New Zealand it is occasionally 
found. Literature is strangely silent about 
South America, but this land is strange to 
us in many other ways. Pirrie gives an 
instance of an English officer in India suf- 

[113] 



HAY-FEVER 

fering there when vegetation was alto- 
gether different from the forms met with 
in England where his attacks had begun. 
As already noted, the complaint has made 
its appearance in two instances when its 
victims were at sea ; one, reported by Ab- 
botts Smith, after shaking ont the sails 
when nine miles out at sea; and another, 
reported by Walshe, in which the patient 
suffered throughout a voyage across the 
Atlantic. A '* sufferer" records that nu- 
merous portions of England, especially the 
highlands and the seacoast, and nearly all 
of Wales and Scotland are exempt from 
the disease. He also regards the upper 
side of the St. Lawrence Eiver, most of 
the province of Ontario north of the Wel- 
land Canal to the Detroit Eiver similarly 
exempt, and he states that the disease is 
wholly unknown to regions above the out- 
let to Lake Huron. 

[114] 



ACCEPTED CAUSES 

Wyman has considered the regions of 
America where hay-fever is especially 
prevalent. That portion of country east 
of the Mississippi Eiver and lying between 
the 35th and 45th parallels of latitude 
he regarded as the territory of prevalence. 
Canada and the Adirondack Mountains, 
the Appalachian range, and the elevated 
plateau throughout New York State 
he considered almost exempt from hay- 
fever. That portion of the United States 
west of the Mississippi Eiver he seemed to 
think, as did Beard also in his later inves- 
tigations, was free from the disease. Beard 
based his reasons upon the lack of vegeta- 
tion and the sparseness of the population. 
Bosworth regards as better reasons the 
rugged mode of life of the inhabitants and 
the consequent vigorous health of the fron- 
tier life. It is a curious observation, too^ 
that certain portions of the "White Moun- 

[115] 



HAY-FEVER 

tains country, formerly regarded as in- 
variably free from hay-fever, of late years, 
probably owing to the extension of civili- 
zation and its vegetation to these regions, 
are no longer exempt from it. Southern 
climates, to a certain extent, are exempt 
from the disease. Wyman thought it did 
not prevail south of the 35th parallel of 
latitude, with the exception of certain 
districts in the neighborhood of Milledge- 
ville, Georgia, Montgomery, Alabama, and 
Beaufort, North Carolina. There can be 
little doubt that the affection is less com- 
mon in Maryland, Virginia, in the border 
States, and in the far West ; that it is rare 
in the extreme South and on the Pacific 
slope. The zone between the 35th and 
45th parallels of latitude practically in- 
cludes the hay-fever district. Even in this 
section, localities, from their proximities 
to large bodies of water or to oceans, to 

[116 ] 



ACCEPTED CAUSES 

elevation or to absence of certain vege- 
tation, afford immunity. A ** sufferer" 
states that on Lake Michigan hay-fever is 
absent above Lndington, while on the Mis- 
sissippi, in Wisconsin, it is present as far 
north as the Chippewa Eiver, and in some 
seasons, in a mild form, it is seen in St. 
Paul, Minnesota. It is known to extend 
to the latitude of Memphis in the West, 
Knoxville centrally, and Cape Henry on 
the Atlantic. In 1896 W. W. Bulette stated 
that in certain sections of Colorado there 
is a variety of the affection known among 
laymen as blossom or cotton-wood fever, 
and very prevalent in regions where the 
cotton-wood tree abounds. The symptoms 
are practically identical with those of the 
autumnal variety of hay-fever, except that 
the throat and bronchial irritations are in- 
tensified, and the course of the attack is 
somewhat shorter. Symptoms occur about 

[117] 



HAY-FEVEE 

the 12th of April and terminate in the 
latter part of May, and rarely last longer 
than July 1st. 

Beard's pamphlet was the first to show 
a radical departure from the pollen theory 
and to establish that the neurotic habit was 
an essential factor. He showed that sub- 
jects of hay-fever often acquired the af- 
fection or the tendency to it through in- 
heritance. The facts sustaining this view 
are of **a most overwhelming character.'' 
Wyman, himself a sufferer, records nu- 
merous cases in his own family through 
four generations. He proved the powerful 
influence of heredity in many of his cases. 
It even appears in childhood, he states, 
and quite generally in those of nervous 
diathesis. In Dr. Morell's family there 
were six sufferers from hay-fever besides 
himself. In the family of Henry Ward 
Beecher there were two besides himself; 

[118] 



ACCEPTED CAUSES 

and Chief Justice Shaw's family contained 
seven. Bosworth says that eighteen of 
eighty cases disclosed direct heredity, 
while in thirty-nine there was either hay- 
fever or asthma in the family. Of the 
forty cases of Sajous ', thirty-five per cent, 
had near relatives who presented clear his- 
tories of hay-fever, and forty-two per cent, 
had asthmatic relatives, while fifty-three 
per cent, of these cases presented a fam- 
ily history of either hay-fever or asth- 
ma. Morell Mackenzie has several times 
treated father and children for hay-fever 
at the same time. Prince relates that five 
members of the same family were hay- 
fever subjects. One daughter of thirty 
years suffered with June cold ever since 
she was ^yq years of age, every year save 
1887, 1888, and 1889. Her grandmother, 
mother, and two brothers suffered alike. 
The daughter, convinced that mental or 

[119] 



HAY-FEVER 

nervous influence affected her, in 1887 was 
treated by the ''mind cure," and for three 
years subsequently was free from her 
symptoms. When the original mind curist 
was dead, in the fourth year, the symp- 
toms returned as badly as ever. Chris- 
tian Science influence was tried in vain. 

There can be little doubt that males are 
more afflicted than females. Of the early 
forms of the disease, however, females 
seem more susceptible than males. Of 433 
cases cited by Phoebus, Wyman, and Beard, 
only 142, about one-third, were females. 
Of 506 cases gathered from several au- 
thors, 342 were males, 164 females. Morell 
Mackenzie met with 38 cases in males and 
23 in females. Men are the more exposed 
to the exciting causes such as dust, heat, 
pollen, etc., altho females are the more 
neurotic. The proportion is about one fe- 
male to three males. 

[120] 



ACCEPTED CAUSES 

Only to some extent can age be said to 
affect tlie disorder. Tlie liability to hay- 
fever in the great majority of cases ap- 
pears before the age of forty. The malady 
has been reported, however, as occurring 
for the first time in persons as old as 
sixty, and persons of seventy and upward 
have suffered. Of the cases of children 
who have been attacked the disease had 
manifested itself in the parents. It would 
have probably been regarded as a common 
cold, had not the parents been the subjects 
of the affection. 

Most all writers on this subject have ob- 
served that the disease attacks the better 
educated classes and those of fair social 
position. It is rarely met with among the 
laboring classes. This would seem to em- 
phasize the view that the disease is essen- 
tially a neurosis. From the notes of sixty- 
one cases of hay-fever in private practise, 

[121] 



HAY-FEVER 

and the sight of many others of which no 
record was kept, Morell Mackenzie found 
all the patients persons of some education, 
and recalled having seen none among his 
hospital patients. Of forty-eight cases of 
Blackley, all were educated, and Wyman 
made the same observation. Holmes has 
shown that the ignorant classes are not so 
likely to recognize the disease as a distinct 
affection, and apply for medical aid 

The fact that the rustic is much less sub- 
ject to this disease than the dweller in the 
city and town, shows the influence of the 
mode of life. Farmers and agriculturists, 
exposed, it would seem, far more to the ex- 
citing causes than others, are peculiarly 
less liable to suffer from it. Beard reports 
only seven such cases among 200. Morell 
Mackenzie states that it is impossible to 
tell whether the villager owes his exemp- 
tion to the maintenance of vigorous health 
[ 122 ] 



ACCEPTED CAUSES 

by an outdoor life, or to habitual exposure 
to the cause of the complaint. 

Holmes admirably points out that **a 
part of the mysterious origin must be set 
down to the indifference of the sufferers 
who, from year to year, have forgotten 
their periodical affection and failed to con- 
sult physicians.'' He says: ^^Of similar 
cause is the groundwork of the assertion 
that it affects only the wealthy. This is 
simply because with this class there is a 
higher intelligence and closer attention to 
ailments, and the fact that having once dis- 
cerned the actual condition, they, in many 
instances, take professional advice or go to 
a place of refuge, thus drawing notice to 
themselves, all of which things are denied 
to the lower (poorer) classes. It is said 
that there are some 200,000 sufferers in the 
United States, at least within the range of 
observation of the Hay-Fever Association, 

[123] 



HAY-FEVER 

whicli, meeting annually at Bethlehem, 
N. H., may be held to represent the more 
stable and well-to-do. From my o^vn ex- 
perience and observation I am convinced 
that there are many of our working peo- 
ple who suffer from this affection who do 
not even recognize the disease." Mer- 
chants, professional men, persons of sed- 
entary habits and brain-workers supply 
most of the victims. The disease is not 
so uncommon among hospital outpatients 
here and in England as formerly. 

Concerning the influence of the neurotic 
tendency, Beard pointed out, in 1876, two 
popular misconceptions of the nervous 
theory, first, that nervous susceptibility 
implies debility and emaciation, whereas 
the nervous temperament is consistent 
with great strength and power of endur- 
ance, especially when combined with the 
bilious and sanguine temperaments; and, 

[124] 



ACCEPTED CAUSES 

second, tliat the nervous theory dispenses 
entirely with the influence of exciting 
causes, as heat, pollen, etc. Beard con- 
cluded that the disease is a complex re- 
sultant of a nervous system especially sen- 
sitive in this direction and acted upon by 
the enervating influence of heat and by 
any one or several of a large number of 
vegetable and other irritants, and this 
view has the advantage over other theories 
in that it accounts for all the phenomena 
exhibited by the disease in this or in any 
other country. He believed that the trans- 
missibility of the disease from parents to 
children; the temperaments of the sub- 
jects; the capricious interchange of the 
early, the middle, and the later forms ; the 
periodicity and persistence of the attacks 
and their paroxysmal character ; the points 
of resemblance between the symptoms and 
those of ordinary asthma; the strange 

[125] 



HAY-FEVEK 

idiosyncrasies of different individuals in 
relation to the different irritants ; the fact 
that it is a modern disease peculiar to 
civilization; the fact that it most abounds 
where functional nervous disorders are 
most frequent and is apparently on the in- 
crease pari passu vnih. other nervous dis- 
eases; and, finally, the fact that it is best 
relieved by those remedies which act on 
the nervous system, — all these otherwise 
opposing and inconsistent phenomena are 
by this hypothesis fully harmonized. 
Prince remarks that altho a nervous orig- 
gin has been recognized by some, still no 
theory has been proposed to show the con- 
nection between the physical symptoms 
and the nervous processes nor the pathol- 
ogy of the nervous processes themselves. 

Vasomotor susceptibility has been viewed 
as indicating the neurotic tendency, and 
this may or may not be due to a central 

[126] 



ACCEPTED CAUSES 

lesion. John N. Mackenzie regarded dis- 
ordered functional activity 'of the nerve- 
centers as the expression of the nervous 
origin. Again, a general neurosis dispos- 
ing to vasomotor disturbance of the sym- 
pathetic and the trigeminus nerves has 
been held responsible. Kinnear speaks of 
two forms, — one a hyperemia, and the 
other an anemia of the sympathetic gan- 
glion. Bosworth is inclined to think a 
peculiar lack of vasomotor control charac- 
terizes the neurotic manifestations. In 
asthma there is undoubted vasomotor pa- 
resis of the blood-vessels of the bronchial 
mucous membranes, while in hay-fever it 
is of the nasal mucous membranes. 

Solis-Cohen regards hay-fever as gen- 
erally a neurosis, primarily a vasomotor 
ataxia or idiosyncrasy. Another view is 
that it may be due to an organic alteration 
of the nerve-fibers terminating in the nasal 

[127] 



HAY-FEVER 

region and chiefly in three reflex areas. 
Again, that it may be dne to functional 
activity or paresis of the governing (vaso- 
motor) centers, accompanied by hyperex- 
citability of the erectile ( cavernous) tis- 
sues aroused by peripheral irritation. The 
phenomena of the cavernous nasal tissue, 
tho secondary to the centric condition, 
indicates a vasomotor disease. Hack and 
Robinson believe the morbid lesion is one 
of neurotic disposition with hyperesthetic 
condition of the olfactory and fifth pair of 
cranial nerves. 

Analogous to the neurotic habit is idio- 
syncrasy. Apparently the same under- 
standing as to what an idiosyncrasy is has 
underlain the use of this word by various 
writers who have advanced idiosyncrasy as 
a cause of hay-fever. Morell Mackenzie, in 
1880, put it down as a predisposing cause, 
but does not say upon what the idiosyn- 

[128] 



ACCEPTED CAUSES 

crasy depends, whether upon some local 
abnormality, the capillaries, the nerve- 
centers, or the periphery of the nerves. 

In 1897 S. Solis-Cohen said idiosyncrasy 
is a real condition in hay-fever, and cited 
the idios;^Ticrasies to salicylic acid, qninin, 
ipecac, opium, etc., as similar to idiosyn- 
crasies that patients exhibit toward the 
different irritants capable of producing 
hay-fever. Using the word to express the 
fact that certain persons react differently 
from most of mankind to certain forms of 
irritation, it means something. It means 
that such persons are abnormal, altho the 
cause of the abnormality remains to be dis- 
cerned. Holmes, speaking of idiosyncrasy, 
would not say there is no such thing as 
idiosyncrasy, but as far as hay-fever went, 
he held that the disease was an actual one, 
the nature of which was not yet com- 
prehended. He remarks that it is quite 

[129] 



HAY-FEVER 

probable that uric acid would aggravate 
hay-fever as it would any other condition 
in the body; and that some think to have 
proved this by the use of salicylic acid, to 
which drug many persons have an idiosyn- 
crasy, thereby aggravating the condition 
in hay- fever by the elimination of uric acid. 

Dr. Samuel Ashhurst, in 1897, recorded 
his habit of regarding hay-fever of late 
years as a personal idiosyncrasy acted 
upon by some irritant, and observed that 
without this personal element it is diffi- 
cult to account altogether for the symp- 
toms and their peculiar periodicity. 

In 1882, Daly advanced the theory of the 
local disease as causative of hay-fever, and 
reported a case in which the patient recov- 
ered after the removal of a nasal polyp, 
which by continuous mechanical irritation 
had doubtless given rise to the condition 
underlying. Examinations of the nares of 

[130] 



I 



ACCEPTED CAUSES 

hay-fever patients have repeatedly failed 
to show any local disturbance other than 
general congestions. Daly's theory was 
subsequently accepted and supported by 
Hack and Eoe, who both affirmed that the 
influence of a morbid condition of the nasal 
mucous membranes favored the develop- 
ment of hay-fever. In 1883 Sajous and 
Herzog wrote important papers to prove 
the same facts. In 1884 J. N. Macken- 
zie demonstrated that ''there exists in 
the nose a well-defined sensitive area 
whose stimulation through a local patho- 
logic process, or through an extra irrita- 
tion, is capable of producing an excitation 
which finds its expression in a reflex 
act or in a series of reflected phenomena." 
He located this area at the posterior end 
of the inferior turbinated bones and corre- 
sponding portion of the septum. It has 
since been held by advocates of the local 

[131] 



HAY-FEVER 

theory, that diseases and abnormalities of 
the nose, snch as a markedly deviated sep- 
tum, outgrowths from the septum, hyper- 
trophic rhinitis, enlargement of the in- 
ferior or middle turbinated bodies, mucous 
polypi, and marked turgescence of caver- 
nous tissue on the inferior turbinated 
body, were all provocative of hay-fever 
paroxysms. 

In 1884, Harrison Allen declared that 
the primary lesion was one of obstruction, 
temporary or permanent, in one or both 
nostrils, from one of various causes, at- 
tendee! by vascular dilatation. Bosworth 
likewise held that the existing morbid con- 
dition of the intranasal tissues must be one 
of an obstructive character, tending to pro- 
duce in itself vascular dilatation. Regard- 
ing nasal polypi, occasionally considered 
as active causes of hay-fever, Bosworth 
concludes that they are rather a result 

[132] 



ACCEPTED CAUSES 

than a cause, since the great quantity of 
ontponred sernm makes the nasal mucous 
membrane sodden or water-soaked, and 
in this way myxomatous degeneration de- 
velops, eventually assuming the form of 
polypi. 

J. N. Mackenzie, however, examined the 
nares of many sufferers from hay-fever 
without finding any nasal lesion. Holmes 
noted an instance most carefully reported, 
in which, with cold snare and galvanocau- 
tery, all obstructions were removed, and 
areas rendered anesthetic so that a probe 
no longer excited reflex symptoms, yet 
the patient suffered from hay-fever with 
scarcely diminished intensity. He further 
observes that at least a degree of the con- 
dition might be the result and not the 
cause, the peripheral susceptibility being 
an outward expression of an inward state. 

In 1885, Thornwaldt, in Wiesbaden, in 

[133] 



HAY-FEVER 

his observations on nasal catarrh, assumed 
that nasopharyngeal disease might not 
only give rise to symptoms simulating 
nasal disease, but was likely the actively 
predisposing cause of asthma and hay- 
fever. Bosworth agreed with him as far 
as hay-fever is concerned. 

In 1893 Seth S. Bishop announced to the 
American Medical Association that **an 
excess of uric acid in the blood causes hay- 
fever, or nervous catarrh." Uric acid in 
the blood in marked excess of the normal 
relation to urea, of about one to thirty- 
three, causes certain disturbances of a vas- 
cular and neurotic character. In health, 
five to eight grains of uric acid are se- 
creted every twenty-four hours. Haig 
claimed that an effect of an excess of uric 
acid is contraction of the arterioles and 
capillaries all over the body. He foxmd 
that by diminishing the alkalinity of the 

[134] 



ACCEPTED CAUSES 

blood it was freed from uric acid, the arte- 
rioles were relaxed, and the headaches and 
mental depression were relieved. Cerebral 
anemia has appeared to obtain in hay- 
fever, and the attacks were relieved, Haig 
f onnd, by such remedies as relieved anemia 
of the brain, e.g., amyl nitrite, coffee, and 
other cerebral stimulants. These views of 
Haig were concurred in by Thomas J. 
Mays, Murchison, Conklin, Ebstein, Quin- 
quaud, and others. Bishop, in 1894, re- 
marked that the blood in the morning is 
more alkaline than at any other time of the 
day, being, at about nine o'clock, at its 
greatest point of alkalinity, which would 
seem to account for those attacks of hay- 
fever which came on early in the morning, 
and which in some instances were as- 
cribed to the influence of light. He was of 
the opinion that not only an excess of uric 
acid in the system, but also an increased 

[135] 



HAY-FEVER 

formation thereof should be regarded in 
the treatment of hay-fever. Bishop also 
claimed that the uric-acid theory was not 
antagonistic to the essentially neurotic 
character of the disease. He also ad- 
vanced that the primary determining cause 
of the particular manifestations in this 
disease is an inherent, perhaps hereditary, 
susceptibility of the nervous system. In 
this way only can we account for the fact 
that the same subjective or objective ex- 
citing cause (uric acid or pollen) will pro- 
duce one train of distressing symptoms 
(nervous coryza) in one individual, and an 
entirely different one in another (asthma). 
This uric-acid hypothesis explains why 
some persons suffer from attacks under 
certain conditions in winter as well as dur- 
ing the warm months. It also unifies all 
the forms. 
Bishop says: "The uric-acid theory of 

[136] 



ACCEPTED CAUSES 

hay-fever is not antagonistic to the present 
status of medical opinion or surgical treat- 
ment, bnt, on the contrary, it explains 
questions that were inexplicable before. 
As a tumor or hypertrophied bone may 
give rise to convulsive seizures in epilepsy, 
and as its removal may be followed by re- 
lief when no other structural cause ex- 
ists, so in hay-fever, when new growths 
and other lesions of the nasal mucous 
membrane are present, the attack may be 
started by the accumulation and the sud- 
den setting free of uric acid. This pre- 
cipitates the paroxysm by its irritant ac- 
tion, which finds expression in the group 
of symptoms characteristic of hay-fever 
or asthma, instead of some one of the other 
allied diseases. The particular form of 
manifestation may be determined by the 
growth or the seat of irritation located in 
the nasal cavities. When this is the only de- 

[137] 



HAY-FEVER 

termining factor of the nature of the mor- 
bid symptoms, no other disease having re- 
sulted from the long-standing trouble, the 
removal of such a peripheral source of 
irritation may give relief from these 
symptoms, but it may not prevent the 
uricacidemia from switching off into other 
kindred lines of disturbances, if it be not 
corrected.' ' 

Capp, in advancing a new theory, in- 
clines to the uric-acid theory, and alludes 
to a certain spastic condition not men- 
tioned by other writers, which, altho slight 
in character, is general, rather than con- 
fined to limited areas, and in a large meas- 
ure accounts for many manifestations of 
the disease. A central nervous irritation 
is probably caused by the presence of a 
disturbing element in the blood, presum- 
ably products of imperfect metabolism not 
eliminated. This may originate nerve-cur- 

[138] 



ACCEPTED CAUSES 

renxs with innumerable reflexes, which, in 
the disturbed equilibrium of the system, 
are, in a measure, uncontrolled by the or- 
dinary inhibition. 

Holmes has very cleverly pointed out a 
fallacy in regard to the evidence advanced 
to substantiate the uric-acid theory. He 
states that some investigators by the use 
of salicylic acid and various acids to 
diminish the alkalinity of the blood, thus 
eliminating uric acid, have, thereby, ac- 
tually aggravated the condition in hay- 
fever, which aggravation has been thought 
due to excess of uric acid in the tissues, or 
increase in its production, instead of be- 
ing due to the idiosyncrasy to salicylic 
acid, etc. 

In 1897, Grayson stated that even if we 
grant that a certain number of hay-fever 
patients are unquestionably people of a 
neurotic temperament, while others are 

[139] 



HAY-FEVER 

gouty, can not we profitably look beneath 
these titles and recognize the fact that they 
are dyscrasies, which are merely different 
offshoots from a parent weed that is 
rooted in defective nutrition? By defec- 
tive nutrition is meant all the phenomena 
of metabolism, — constructive, destructive, 
and eliminative. Disturbance of one means 
disturbance of all. "With continued ab- 
sorption of toxic materials from the intes- 
tinal tube, or with persistent incomplete 
elimination of the products of suboxida- 
tion, it is only a question of time when au- 
totoxemia will provide us with any of the 
functional neuroses from hay-fever and 
asthma to chorea and epilepsy. 

Grayson says the neurotic habit may ex- 
ist, but it is not essential to the disease, but 
the nervous system is implicated as a vic- 
tim, not as a culprit. He claims that hay- 
fever is a defect, not of the nervous, but of 

[140] 



ACCEPTED CAUSES 

the nutritive system, because impairment 
of the digestive and nutritive processes is 
almost invariably the first downward step 
toward a general state of lowered vitality. 
At first gastric, it later involves the whole 
gastro-intestinal tract. He thinks uric acid 
is almost invariably present in excess in 
hay-fever subjects. A child having reflex 
convulsions due to acute indigestion is not 
a neurotic subject, yet the vasomotor per- 
turbation of the hay-fever patient differs 
from that of the child mainly in point of 
chronicity. 

Grayson concludes that the three factors 
which make up the etiologic combination of 
hay-fever are: An external irritant, some 
intranasal abnormality, and a constitu- 
tional element — * * defective nutrition. ' ' 
The physician unaided can not restore the 
nose to a state of health. In order to over- 
come the self-indulgence of the patient, 

[141] 



HAY-FEVER 

regularity is recommended in eating, work, 
and play, while indiscretions of diet, lack 
of exercise, objectionable fancies in mat- 
ters of clothing and bathing, and, finally, 
vicions excesses — alcoholic, narcotic, or 
sexual — will require the constant and most 
determined effort of the patient himself. 
The whole environment of the patient must 
be separately studied and provided for in 
the dietary scheme. A comment on this 
treatment is: "While it is true that if a 
man takes care of his muscles his nerves 
will take care of themselves, there is no 
closing of the eyes to the fact that to the 
average man exercise is distasteful ; there- 
fore, it is the more necessary to be explicit 
in instructions concerning it. Altho there 
is nothing brilliant about this method of 
removing the constitutional factor of the 
disease, what it lacks in brilliancy is more 
than made up in certainty, and if the 

[142] 



I 



ACCEPTED CAUSES 

patient is possest of grit and determina- 
tion it brings a sure reward." 

J. Mliller thinks there is a causal rela- 
tion between hay-fever and gastro-intes- 
tinal symptoms, but he also holds that it 
can be proved that pollen entering the 
respiratory tract is the cause of the dis- 
ease. A *^ sufferer," writing on the dis- 
ease, says: '^Indigestion is a most potent 
cause in many instances, and proper food, 
properly digested and assimilated, has 
permanently relieved more than one. ' ' But 
he does not say he himself was relieved, 
nor does he give cases. 

It is questionable whether or not the di- 
gestive disturbances are not effects rather 
than causes of the disease. It is not at all 
doubtful, however, that lowered resistance 
and a depreciated vitality may result from 
difficulty in the gastro-intestinal tract. 
Such difficulty may suffice to start the 
chain of hay-fever symptoms. 

[143] 



PART III 
POEMS OF TKEATMENT 



[145] 



PART III 

FORMS OF TREATMENT 

1. Preventive Measures 

In the young we find preventive treatment 
giving the greatest rewards. This calls for care- 
ful attention to the general health of the grow- 
ing child. The medical profession has done 
much to awaken an interest in preventive meas- 
ures among parents, and in no way has the fam- 
ily physician reduced infection more thoroughly 
than by insisting on a careful toilet of the nose 
and throat. In this way he has very frequently 
prevented many of the more serious diseases of 
the growing child. Personal hygiene is as val- 
uable as domiciliary hygiene, yet, if either is 
neglected disease is certain to continue. 

The careful parent will insist upon frequent 
professional examinations of his children and 
at the first sign of discomfort have any abnormal 
condition corrected. It is not wise to wait until 
distress compels relief, and if hay-fever is an 
inheritance in a family it is especially impor- 
tant. Children with enlarged tonsils and ade- 
noids should have them removed not only to in- 
[147] 



HAY-FEVER 

crease their mental poise but to secure their 
physical comfort, and also as a step in escaping 
hay-fever. Adenoids are frequently the cause 
of broken rest at night, with earache, a tendency 
to repeated bronchitis; this is seen more fre- 
quently during spring and fall. This condition 
may bring on change in voice and ofttimes a 
running nose. With enlarged tonsils we fre- 
quently encounter the unproductive cough. 
We may mention, while passing, that enlarged 
tonsils remaining after the tenth year should 
be removed, as they are undoubtedly hopelessly 
diseased. I am a firm believer that tonsils and 
adenoids should be removed early, for, in addi- 
tion to this local discomfort, they influence the 
mental health by rendering possible a more 
systemic depreciation of the child. The frontal 
sinus may become involved as well as the eth- 
moid. Young children are frequently found to 
suffer with deviated septum and this contributes 
to the general discomfort. With the pressure of 
retained secretion polypi are not unusual. 

Ballinger has been imprest with the possible 
relationship of catarrhal sinusitis, particularly 
ethmoidal and frontal, to hay-fever. He has 
found surgical treatment of the sinusitis to be 
followed by relief of the hay-fever. The diffi- 
culty in the way of diagnosticating catarrhal 
sinusitis has been so great that it has been fre- 
quently unrecognized. Hay-fever due to catar- 
rhal sinusitis has been cured by Dr. P. M. Far- 
rington, of Memphis, by the use of autogenous 
vaccine. 

[148] 



FORMS OF TREATMENT 

Dr. Ballinger quotes the late Dr. Schadle, 
who called attention to the possibility of rela- 
tionship between maxillary sinusitis and hay- 
fever. Whether or not such a relation exists, 
we must recognize the fact that the local hyperes- 
thesia probably has an anatomical or inflam- 
matory origin. The hypersensitiveness does not 
"happen" but has a definite cause. The hy- 
pothesis is still further supported by clinical 
facts — that some cases of hay-fever are cured 
by successful treatment of the sinusitis. Hered- 
ity may impress a neurotic temperament on the 
growing child with tendency to gout or rheu- 
matism. This unstable condition of the nervous 
system is difficult to define, there may be an 
excess or decrease in the nervous energy. There 
may be a faulty metabolism whereby certain 
toxic substances are liberated in the blood cur- 
rent. That hay-fever subjects are usually neu- 
rotic has been generally accepted. "Why they 
are neurotic is a much mooted question, concern- 
ing which ingenious theories have been advanced, 
but none of which are convincing. 

Preventive treatment for hay-fever, therefore, 
must take in family history and family tendency 
in 'an endeavor to correct local, as well as con- 
stitutional faults. This intimate knowledge of 
family history gives the physician the insight to 
the constitution of the child. Heredity may do 
much to balance or unbalance nervous energy, 
it may do more to handicap a child physically, 
but I am of the opinion that environment plays 
a most important role in the growing child. In 
[149] 



HAY-FEVER 

childhood preventive measures yield the best re- 
turns, and this is well illustrated in the develop- 
ment of hay-fever tendency, and it is wise that 
the masses have grown active to the needs of the 
young. 

As an important feature in preventive meas- 
ures I can do no better than quote here the ar- 
ticle of Dr. Scheppegrell, the president of the 
American Hay-Fever Prevention Association, 
on ' ' Hay-Fever ; Its Cause and Prevention. ' '* 

''From the standpoint of the number of pa- 
tients affected, hay-fever ranks among the first 
of the non-fatal diseases. While accurate sta- 
tistics regarding the number of patients are 
not available, a conservative estimate has placed 
the number of persons in New Orleans affected 
with hay-fever at not less than 3,500, or one 
per cent, of the total population. Hay-fever is 
prevalent in the greater portion of the United 
States, and the proportion in New Orleans is a 
fair average of its prevalence in other sections. 
The total number of those suffering from this 
disease, therefore, is so large that the subject 
demands the most careful consideration. 

''In spite of the greater increase in medical 
knowledge, many cases of hay-fever are still 
mistaken for ordinary colds. The symptoms 
described and their recurrence at certain periods 
of the year should simplify the diagnosis. In 
doubtful cases this may be confirmed by testing 

^Published in the Journal of tlie American Medical 
Association for Marcli 4, 1916. 
[150] 



FORMS OF TREATMENT 

the patient with a small amount of pollen. 

'^Some of the staminate flowers of the sus- 
pected plant are placed in a small sterile gauze- 
bag, and this gently sniffed by the patient. In 
susceptible subjects this is quickly followed by 
a slight reaction. The patient may also be 
tested by approaching the suspected weeds so 
that some of the pollen is inhaled in this way. 

' ' In the majority of cases, however, these tests 
are unnecessary and should ordinarily be avoid- 
ed on account of the danger of developing a 
latent pollinosis. The beginning and end of the 
attacks are usually found to be coincident with 
the pollinating period of certain plants with 
wind-borne pollen, which, with the symptoms 
described above, is sufficient to confirm the diag- 
nosis. 

''Some physicians still believe that hay-fever 
is a local manifestation of some constitutional 
condition, in spite of the fact that the majority 
of patients, with similar conditions, have no such 
manifestations, and that when the pollen is not 
present, as on a sea trip, they do not occur. 
Improved education in the etiology of this dis- 
ease, and more careful observation, will grad- 
ually correct this error. 

"Even had therapeutic measures been more 
successful, prophylaxis, based on the removal 
of the exciting cause, should have been advo- 
cated as in malarial and typhoid fevers, tuber- 
culosis and other diseases of known cause. Hay- 
fever, however, has been the stepchild of pre- 
ventive medicine, and until recently no organ- 
[151] 



HAY-FEVEE 

ized efforts in this direction have been under- 
taken. 

"In view of the great and increasing number 
of hay-fever patients, their prolonged distress, 
the unsuccessful results of all curative measures 
and the distinctive preventable character of the 
disease, the American Hay-Fever Prevention 
Association has undertaken a campaign of edu- 
cation, to be followed in due time by suitable 
legislation, for the prevention of hay-fever. 

' ' In the educational part of this work, the first 
consideration is the correct diagnosis of hay- 
fever and the acceptance of the fact that all 
cases of true hay-fever are the results of pollen 
inhalation. 

"The identification of the various weeds and 
plants that may develop hay-fever is of the ut- 
most importance, but will gradually follow the 
establishing of the etiology of pollinosis. As 
these principles become better understood, the 
physician, when consulted by a patient with 
hay-fever, instead of limiting his attention to 
writing a prescription or injecting a vaccine, 
will investigate the presence of hay-fever-pro- 
ducing weeds in the neighborhood of the pa- 
tient's residence or vocation. In many cases 
the eradication or even the cutting of such weeds 
produces immediate results. 

"In one of my patients, the offending weed, 
Amhrosia art emisiae folia [ragweed] was grow- 
ing in his garden. In another, a school-teacher, 
affected with hay-fever for many years, on being 
questioned stated that there was an abundance 
[152] 



FOEMS OF TEEATMENT 

of flowering weeds in the vacant lots adjoining 
her house. When specimens of these weeds were 
produced they were found to be the Parthenium 
hysterophoroiis, one of the causes of hay-fever 
in south Louisiana. In both of these cases 
marked relief soon followed the cutting of these 
weeds. In order to obtain complete relief in 
such cases, however, the cutting of the weeds 
should be over a considerable adjoining area, as 
the pollen is wind-borne to a distance depend- 
ing on the velocity of the wind. 

"While the removal of the offending weed is 
the correct measure, relief may also be obtained, 
when this is impracticable, by avoiding the 
proximity of weeds known to be toxic to the 
patients. In maay cases this is entirely prac- 
ticable, as shown in the following case in which 
the attack was postponed for thirty-three days: 

"E. G., manager of a sugar plantation near 
New Orleans, has been a sufferer from hay-fever 
for the past ten years, the attacks always com- 
mencing about August 25th. After the influence 
of the ragweed to this form of hay-fever had 
been explained to him, he concluded that his at- 
tacks were due to the pollen of the trifida rag- 
weed which grows on a road some distance from 
his residence. He, therefore, avoided the road, 
and until September 28th, for the first time in 
ten years, he had had no attack. On this date 
he found it necessary to pass this road. In 
twenty minutes he commenced to sneeze, that 
night he had a violent attack, and the follow- 
ing day he had his usual annual hay-fever. 
[153] 



HAY-FEVER 

**The treatment of cases by the eradication of 
the hay-fever-producing weeds will not only 
produce direct results, but will also prove a 
powerful impetus in educating the public in the 
relationship of such weeds to hay-fever. It will 
result, moreover, in having these weeds con- 
sidered from a new point of view. Instead of 
simply indicating neglect or careless cultivation, 
they will be looked on as a source of disease and 
discomfort to a large class of sufferers. This 
will not only bring the leverage of public opin- 
ion to the eradication of these weeds, but will 
eventually simplify the question of legislation. 

*'In connection with the question of public 
education, the American Hay-Fever Prevention 
Association has received a communication from 
Dr. Eupert Blue, surgeon-general of the United 
States Public Health Service, and one of the 
honorary vice-presidents of our association, in 
which he summarizes this in a very concise 
manner : 

" 'It appears that the most practical method 
of securing the cooperation of the public would 
be by education as to the effect of the presence 
of these weeds in communities from both health 
and economic standpoints. This seems to be the 
primary object of your association, which is to 
be commended for its efforts.' 

''Some of the early forms of hay-fever are 
due to the pollen of the Graminaceae or grasses, 
which include the cultivated varieties, such as 
rye, wheat, com, etc. These form a common 
cause of hay-fever in England and on the Conti- 
[154] 



FOEMS OF TEEATMENT 

nent, where the autumnal form due to the rag- 
weed is not found, owing to the absence of the 
weed. 

"While this is of much less frequency than 
the fall hay-fever in the United States, it repre- 
sents in the aggregate a considerable number. 
When these cases are due to the cultivated va- 
rieties, the knowledge of this fact should induce 
the patient, whenever possible, to live away from 
such cultivated fields or at least +o avoid them 
during the active season of pollination. Only 
in those cases in which the removal of the offend- 
ing plant is impossible will the question of 
treatment be given preference over prevention. 

*'As the autumnal hay-fever is the most prev- 
alent form in the United States, and, in the 
majority of cases, is due to ragweed, the Amer- 
ican Hay-Fever Prevention Association has 
given its first attention to the eradication of 
this weed. The description and illustration of 
both varieties {Ambrosia art emisiae folia and 
trifida) have been sent to the State boards of 
'health of each State and of the District of Co- 
lumbia. Many of these have published the cuts 
and descriptions, and a number have sent them 
to the newspapers of their State for j ublication. 

"The United States Department of Agricul- 
ture has assisted and is furnishing valuable in- 
formation for this work. Arrangements have 
been made with the Hygienic Laboratory of the 
Public Health Service at Washington to make 
investigations on the hay-fever pollens submitted 
by our research dejjartment. Encouragement 

[155] 



HAY-FEVER 

or promise of active cooperation has been of- 
fered by the majority of the State boards of 
health, these being as follows: Arkansas, Ala- 
bama, Arizona, California, Colorado, Delaware, 
Florida, Idaho, Indiana, Iowa, Kansas, Ken- 
tucky, Louisiana, ^lassaehusetts, Michigan, Min- 
nesota, Nevada, New Hampshire, New Jersey, 
New York, North Carolina, Oregon, Tennessee, 
Utah, Virginia, Washington, We^ Virginia, 
Wisconsin and Wyoming. 

"The common ragweed {Ambrosia artemisiae- 
folia), while found in great abundance, pre- 
sents no special difficulty in eradication, as it 
is an annual and reproduced only by seed. In 
carefully cultivated lands it is not found in 
appreciable quantities. Where the land is not 
cultivated this weed may be entirely kept down 
by grazing cattle. When, however, it has been 
neglected, the weed should be mowed before the 
latter part of August, in order to prevent 
pollination. 

"The giant ragweed (Amhrosia trifida), 
which grows in similar abundance in the moist 
lands of the coast, presents a more difficult prob- 
lem, as the roots are perennial. Until this weed 
is two feet in height cattle will feed on it with 
avidity, which will probably prove useful in de- 
stroying it. In carefully cultivated lands it is 
rarely found. The question of the best scientific 
method of eradication of both the ragweeds has 
been referred to the United States Department 
of Agriculture, and the results of this investi- 
gation will be reported later. 
[156] 



FORMS OF TREATMENT 

''With a view of showing what can be accom- 
plished by organized efforts in the prevention 
of hay-fever, the American Hay-Fever Preven- 
tion Association has concentrated its first efforts 
in New Orleans in the following msmner: 

*'The public was first educated regarding the 
ragweeds, so that they could be easily recog- 
nized. Illustrations of the weeds were published 
in the Bulletin of the State Medical Board of 
Health and the public press, and the live weeds, 
in full development, were exhibited in a show- 
window of the principal street. 

''The city of New Orleans, through the com- 
missioner of public works, placed at the dis- 
posal of the association twenty convicts, who 
cleared the streets and sidewalks of the outer 
sections of the city of the weeds, in accordance 
with a map prepared by the topographic com- 
mittee of the association, showing the areas 
infected with ragweed. The city board of health 
assisted by enforcing the cutting of weeds in 
vacant lots and the commissioners of the various 
parks had the ragweed destroyed in the public 
parks under the direction of the association. 

"Valuable assistance was given by the Wom- 
en's Civic League, which appointed a special 
committee on vacant lots. This committee made 
arrangements with labor bureaus so that it not 
only reported lots infected with weeds, but of- 
fered to send workmen to cut them at low rates. 

"The storm of September 29 destroyed prac- 
tically all the leaves and flowers of the remain- 
ing giant ragweed in exposed places. As a 
[157] 



HAY-FEVER 

result of this, and the efforts of the American 
Hay-Fever Prevention Association, fall hay- 
fever practically disappeared in New Orleans 
several weeks earlier than the usual time. This 
campaign will be resumed next spring, when its 
management will be placed in the hands of the 
State Hay-Fever Association. 

*'The American Hay-Fever Prevention Asso- 
ciation believes that what has been effected in 
New Orleans can be done in all towns and cities. 
In some of the smaller towns, especially those 
catering to summer visitors, this could be 
accomplished before next summer. The state- 
ment that a town is free of hay-fever will prove 
an advertisement that will easily repay the cost 
of destroying the hay-fever-producing weeds.'* 

2. Local Treatment by Nasal 
Applications 

Local treatment of hay -fever has been viewed 
with diverse opinions by every writer on the 
subject. Many good authorities condemn all 
internasal treatment as useless and irritating, 
while others strongly advocate its value. It 
needs no argument to show the value of nasal 
and throat applications of antiseptic nature in 
the early stages of influenza or any other neu- 
tral catarrhal irritation of the eye, nose or 
throat. Indeed many household epidemics have 
been shortened or aborted by the careful atten- 
tion to these parts. I am not alone in the state- 
[158] 



FOEMS OF TKEATMENT 

ment that severe household epidemics have been 
deprived of their danger by careful cleansing of 
the nasal mucous membrane before the infection 
became systemic. Indeed, this is the routine 
treatment in every well-regulated family where 
children are found, especially during winter and 
spring, and in the early fall. It is much more 
important that this should be carefully observed 
if the neighborhood is infested with an epidemic 
of catarrhal colds. The repeated infection of 
some families and the escape of others is not so 
much in the vital resistance of the several mem- 
bers, but the neglect in the individual of per- 
sonal hygiene. This is true of all diseases, as 
well as of hay-fever. It is true that children, 
and young people in general, are more likely to 
contract catarrhal colds if they are burdened 
with adenoids or hypertrophied tonsils — dis- 
eased by repeated former attacks. I believe 
that the acute infectious diseases, particularly 
in children, may be lessened by most thorough 
and repeated sterilization of the nasopharynx, 
and just as house epidemics are never excusable 
evils so I claim the same to be eventually true of 
hay-fever. 

The important result to be obtained through 
local treatment is the prevention of the parox- 
ysms, and, ultimately, the removal of the re- 
curring habit periods; i. e., the destruction, if 
possible, of the recurring habit. Years ago I was 
led to treat my hay-fever patients by cleansing 
the nasopharynx with an atomizer containing a 
warm solution of boric acid (ten grains to an 
[159] 



HAY-FEVEE 

ounce of water) or Dobell's solution, after 
which I carefully wiped the mucous membrane 
and applied menthol and camphor and liquid 
cosmoline freely to the parts. This procedure 
afforded considerable temporary relief in a large 
number of cases when there was present simply 
turgescence of the whole nasopharynx. 

IJ. Sodium bicarbonate, 

Sodium borate aa ^iss 

Carbolic acid ^j. 

Gylcerin ^ij. 

Eose water (25 per cent.) q.s. Oj. 

SiG. — Teaspoonful to one ounce of warm water. 

This I thoroughly use in both nostrils, first 
by means of an atomizer, after which, with a 
curved applicator or cotton-carrier, I very care- 
fully swab the whole nasopharynx. I scrub 
most carefully and gently every portion of the 
mucous membrane, being sure to reach between 
the turbinated bones and all around and over 
every slight prominence. I then as carefully 
dry the membrane with clean cotton, and use 
freely a mild solution of menthol and camphor 
in aJbolin, in proportion as follows: 

IJ Menthol , gr. v. 

Pulverized camphor gr. v. 

Albolin ^ij. 

I loosely plug the nose for a few minutes 
to retain the oily application. It is important 
to sterilize most thoroughly the sensitive areas 
[160] 



FOEMS OF TEEATMENT 

of the nose, as we are unable to determine 
whether one or more may be affected, and by 
this mild yet thorough treatment we cleanse 
effectually the whole nasal chamber. 

This treatment was so extremely simple 
that for a long time I doubted its real value, 
but as so many sufferers have exprest their 
relief, and were willing and anxious for me to 
continue the applications, I have concluded to 
offer my methods in full confidence of their 
usefulness, with a warning that for successful 
treatment the instructions for cleansing and 
scrubbing must be followed in careful detail. 
Good results need not be expected by simple 
irrigation and swabbing — the whole nasal mu- 
cous membrane must be thoroughly washed and 
gently scrubbed before the oily applications are 
used. 

This intemasal treatment should commence 
four weeks before the expected onset of the 
paroxysm, and should be done daily, if possible. 

I have found many persons who will not toler- 
ate the use of carbolic acid, even in so mild a 
solution as that given above, the weakest solu- 
tion frequently causing a severe urticaria.. 

When various idiosyncrasies to carbolic acid 
forbid its use, I select as the second best de- 
tergent hydrogen dioxid, and commence with 
the following mixture: 

IJ Hydrogen dioxid, 

Glycerin aa ^ss. 

Distilled water q.s. 5^^ 

[161] 



HAY-FEVER 

With this I spray the nose most thoroughly, 
following it up with plain warm normal salt to 
remove the accumulation of foam that will neces- 
sarily collect in the nasal spaces. A few days, 
or, better, one week prior to the date of the 
onset, I increase the strength of the hydrogen 
dioxid solution, using something like the fol- 
lowing : 

IJ. Hydrogen dioxid ^ij. 

Glycerin, 
Distilled water aa ^ij. 

This must be removed also by means of the 
normal salt, as already mentioned. In a number 
of cases I have found glycerin objectionable as 
a vehicle, producing an irritation of much an- 
noyance. In such cases I omit the glycerin and 
substitute normal salt. In a few cases, the hy- 
drogen dioxid produced an inflammation of the 
mucous membrane that would require its dilu- 
tion. We find many personal idiosyncrasies in 
a large number of hay-fever sufferers that one 
might go on indefinitely with modifications of 
treatment, but, as in general practise, it is our 
aim to treat the individual primarily, and we 
can not dogmatically hold fast to any special 
drugs or formula. 

In the few obstinate cases in which steriliza- 
tion seems to provoke trouble, and the slightest 
manipulations of the nose and throat precipitate 
violent paroxysms, I use the following: 
[162] 



FOEMS OF TREATMENT 

5». Morphia Muriate gr. i 

Menthol pulv gr. ii 

Boric acid gr. x 

Camphor pulv gr. xii 

Starch pulv z. iv mft. 

SiG. — Use as a snuff, frequently. 

The following to be taken internally: 

IJ. Tablet Suprarenal Ex. gr. v. 

SiG. — One every three or four hours. 

Many physicians claim that relief can not be 
afforded to hay-fever patients without using co- 
cain or eucain at some time during the manage- 
ment of troublesome cases. It is very excep- 
tionally that I resort to either; possibly an un- 
usual case will require one or more applications 
to control a local storm, yet the majority of 
patients never receive cocain from my hand. 

In severe cases that came under my care after 
the disease had been well established, when I 
had no chance to conduct a preliminary course 
of benumbing, I have been forced to prescribe 
something like the following : 

Menthol gr. viij. 

Boric acid gr. xxx. 

Albolin ^ij 

Solution of Eucain ''B" (4 per cent.) .... ^ij 

This is applied carefully and thoroughly on 

cotton applicators to the mucous membrane of 

the nasopharynx. It may control the attacks, 

and it frequently aborts them and keeps the 

[163] 



HAY-FEVER 

patient decidedly comfortable. I have found 
the direct application of the remedy more satis- 
factory than the atomizer. In some cases, for 
a few days, this application must be made two 
or three times daily. 

H. L. Swain recommends the local use of 
the aqueous extract of the suprarenal glands in 
certain chronic conditions of the hay-fever type, 
as a powerful local vaso-constrictor and con- 
tractor of erectile tissue. The local effect can 
apparently be obtained any number of times 
without entailing a vicious habit, such as might 
result from cocain. Ingals and Ohls report that 
they have obtained much relief in these cases 
by the use of an extract of suprarenal capsule 
prepared as follows: Adrenals (Armour's), 
§j ; boric acid, gr. xvj ; cinnamon water, 3iv ; 
hot camphor water, gi ; hot distilled water, 
enough to make §ij. Mix, macerate for four 
hours, and filter. This solution remains stable 
for several weeks. It is used as a spray four 
or five times a day. I have not had occasion 
to resort to the local application of this sub- 
stance, but I have had one patient who was dis- 
tinctly benefited by internal administration in 
doses of gr. i/4 to gr. j, as often as four times a 
day. He was a catarrhal young man of neurotic 
temperament, who came to me during the first 
week of his attack, and who objected to the usual 
routine sterilization of the nasopharynx.* 

^Personally tlie use of the suprarenal extract has been 
of little value owing to the violent sneezing provoked. 
[164] 



FOEMS OF TEEATMENT 

The formula : 

Adrenal chlorid 3ij« 

Normal salt sol q.s. Jj. 

is more elegant and convenient. 

3. As TO Diet, Exercise and Rest 

In old cases, when the nerve-habit has long 
been formed, treatment should commence at 
least two or, better, three weeks before the an- 
ticipated recurrence of the paroxysms. All 
bodily irregularities must be corrected and ten- 
dencies to constipation or dyspepsia removed. 
Amylaceous indigestion should be corrected by 
the exclusion from the dietary of too starchy 
foods. For the elimination of excessive uric 
acid, or other waste products, and to relieve 
constipation, the systematic administration, 
morning and night, of sodium phosphate, is in- 
valuable. If the appetite is not good, the regular 
use of the tincture of nux vomica, ten to 
twenty drops three times a day, is strongly in- 
dicated. In anemic cases pills of carbonate of 
iron or, probably still better, the pills of valer- 
ianate of quinin, iron, and zinc are necessary. 
In nervous cases with anemia, valerianate of 
zinc, one grain, with two grains of the compound 
asafetida pill, two or three times a day (after 
Morell Mackenzie), will be found valuable. 
Careful diet, a tranquil mind, and moderate ex- 
ercise are essential. Outdoor exercise, with a 

[165] 



HAY-FEVER 

daily tepid bath followed by vigorous friction 
of the whole body, will help to eliminate waste 
material. The patient should not unnecessarily 
expose himself to direct rays of the sun, as they 
are calculated to excite intense reflex irritation 
of the sensitive nerve centers. Much trouble 
may be averted by the use of a sunshade or 
umbrella and by the avoidance of exercise in 
the sun. 

It must be understood that with the general 
hygienic and constitutional treatment the course 
of local prophylaxis by daily sterilization is 
most necessary. 

The treatment of neurasthenic cases, or those 
in which a decided derangement of the general 
system as well as of the nervous energy exists 
prior to the attack, requires the greatest tact 
and skill. If there is little local catarrhal dis- 
turbance there will be great difficulty in com- 
bating the disease in the face of the deprest 
vitality and lessened nervous resistance. In such 
cases I place the patients upon a diet, somewhat 
like that in the appended list, and urge strict 
adherence to it. After obtaining careful urinary 
analysis and other clinical data, I often further 
specialize in the diet, or I may increase the 
variety according to the needs of the individual. 
In these cases I always urge the drinking of 
large quantities of water, unless there is some 
strong contraindication. Neurasthenics will often 
avoid water between meals. I at once order sys- 
tematic massage. If the patient does not care 
tor a masseur, I order a daily tepid bath of a 
[166] 



FOEMS OF TEEATMENT 

temperature between 80° and 85° F., with, a 
coarse towel rubbing, followed by a douche of 
cold water along the spine. This should be 
continued for at least two weeks prior to the 
onset of the paroxysms. 

Rest for the overtaxed function is impera- 
tively demanded. Unfortunately, this is more 
easily prescribed than carried out. In wealthy 
patients the Weir-Mitchell rest-cure often gives 
brilliant results. In other cases a change of 
scene 'and a temporary rest from business or 
society may be accepted when the sanitarium 
would be out of the question. Quiet resorts on 
the sea coast or in the mountains are desirable. 
Nothing is better than two or three weeks on 
the ocean. A compromise may be obtained by 
having the patient give up a portion of the 
daily duties and go to bed earlier at night. The 
patients should not be allowed to discuss their 
ailments too freely. Horseback riding, bicy- 
cling, rowing, and walking — in fact, any out- 
door diversion not too violent — are to be recom- 
mended. 

If the patient suffers from insomnia, careful 
administration of a hypnotic may help to re- 
establish the sleep-habit. At first give a warm 
bath, and a glass of warm milk or malted milk 
before retiring. If this and other similar meas- 
ures do not avail, five grains of Veronal cap- 
sule may be given one hour before going to 
bed. If the patient is accustomed to awake 
after a short sleep, the Veronal should be given 
at bedtime. Full amounts of sleep are neces- 
[167] 



HAY-FEVER 

sary to neurasthenics. Depressants, such as 
the bromids, chloral, and the opiates should be 
avoided. Any coexistent gastric or cardiac trou- 
ble must be carefully treated, and the bowels 
kept open regularly. 

The diet that I find most desirable to follow, 
generally speaking, is that which is applicable 
to the gouty or uric acid diathesis. 

General Rules. — The diet should be liberal, 
but not stimulating, with moderation in animal 
foods and very little of foods having a ten- 
dency to produce acids in the system, such as 
starches, sugars, fats, and fermented liquors. 
Patients may take soups — clear or vegetable — 
and weak beef tea or broths. 

Fish. — Fresh fish and raw oysters. 

Meats. — To be taken once a day only — mut- 
ton, chicken, underdone roast, sweetbread. 

Eggs. — ^IVIoderation. White of eggs, raw, or 
shirred in drinks, such as lemonade, occasion- 
ally. 

Farinaceous. — In small quantities. Toast, 
stale bread, bread from whole wheat, rye bread, 
milk toast, rice, crackers. 

Vegetables. — Fresh, green varieties prefera- 
ble; celery, lettuce, watercress, cucumbers, 
onions, cabbage, salads, sparingly of baked po- 
tatoes, young peas, string beans, and spinach. 

Desserts. — Oranges, lemons, apples, apricots, 
pears, peaches, cherries, blanc-mange (not after 
meals, however), stewed fruit. 

Beverages. — ^Water, plentifully, especially be- 
fore meals; plain soda, milk, buttermilk, weak 
[168] 



FOEMS OF TEEATMENT 

tea or coffee (without sugar), toast-water, lemon- 
ade. Mineral waters, such as Saratoga Vichy, 
Berkele}^ (Hot Springs), Lithia Water, Carls- 
bad, and Crab Orchard. 

Stimulants. — Light Hock; Bordeaux in small 
quantities and well diluted. 

Articles Forbidden. — Patients must avoid 
rich soups, hard-boiled eggs, fried and made 
dishes of all kinds, entrees, pickles, spices, veal, 
pork, duck, goose, salmon, lobster, crab; pre- 
served, dried, and salted meats ; salt fish, pickled 
pork, asparagus, old peas, beans, tomatoes, mush- 
rooms, truffles, dried fruit, preserves, pies, 
pastry, rich puddings, patties, new bread, cheese, 
sweets, malts, sweet wines, strawberries, rhubarb, 
cider, fermented drinks, beer. 

4. When Asthma Occurs as a Sequel 

About five to ten per cent, of my whole num- 
ber of hay-fever patients have suffered more or 
less from asthma. Asthma, as a sequel in these 
cases, manifests itself about the end of one week 
or ten days after the expected paroxysms of 
hay-fever, and is induced usually by some undue 
exposure or a damp or rainy day. My asthmatic 
patients, I find, were among those irregular in 
treatment, or those who had first called late in 
the disease. In these cases much mucous had 
accumulated in the larger tubes. If I can not 
clear the bronchial tubes by an emetic dose of 
ipecac, I prescribe somewhat as follows: 
[169] 



HAY-FEVEE 

Potassium iodid 5s8 

Ammonium muriate 3ss 

Sirup of Yerba Santa Jj, 

A teaspoonful administered every two hours 
generally brings relief. A number of asthmatic 
patients require a solution of nitrogylcerin, one 
per cent. Of this, one drop every two hours for 
two or three days is given. Occasionally it 
seems imperative to give morphin. Some of my 
asthmatics have informed me that they can bring 
about immediate relief by plunging both hands 
in hot water and taking a drink of whiskey, fol- 
lowed by a large draft of hot water. It is 
possible for some persons to voluntarily combat 
their asthmatic attacks, and for this reason they 
should be encouraged to practise certain breath- 
ing exercises until they can in a measure con- 
trol their respiratory apparatus. Asthmatics 
usually have, however, a preexistent catarrhal 
state of the bronchial tubes, which exhibit 
marked vasomotor changes on slight irritation. 
If I see these patients early, I prescribe five- 
minim capsules of the oil of sandalwood four 
times a dsiy, or the compound salol capsule, and 
by the time their period arrives, the bronchitis 
is fairly well cleared up. 

The inhalation of the fumes of burning niter- 
paper or specially prepared powders, or of cig- 
arets, gives relief in many cases. The powders 
used at the Brompton Hospital by Sidney Mar- 
tin contain one part each of anise and niter, 
two parts of stramonium leaves, and five grains 
[170] 



FOEMS OF TREATMENT 

of tobacco to the ounce; one teaspoonful is to 
be burnt on a plate and the fumes inhaled. A 
pill containing 14 of a grain of morphin, with 
1/200 of a grain of atropin sulfate, given at 
bedtime, is sometimes useful in connection with 
the inhalations. Extract of stramonium (1-16 
of a grain) may be substituted for the atropin. 

Van Sweringen calls attention to a line of 
treatment in a very obstinate case of bronchial 
asthma that was attended by remarkable results. 
The attack had lasted for two weeks, during 
which time all the antispasmodics had in turn 
been exhausted, and the patient had secured but 
a period of two hours' freedom at any one time. 
Finally, based on the theory that if asthma was 
a reflex it must be under the control of Setsche- 
now's inhibitory center, and that anything that 
would stimulate the inhibitory center would 
lessen the reflex-spasm, quinin and strychnin 
were given, with excellent results. The dose of 
the quinin was seven grains. The extract of 
nux vomica was given in %-grain doses, and to 
this was added i/4 of a grain of codein sulfate. 
In the interval the iodids were continued. 

However, the use of sedatives and inhalations 
must be limited, especially in the milder and 
uncomplicated forms of asthma, while efforts to 
benefit the patient's general condition are 
strongly indicated. Diet is an important part 
of the treatment of many cases. Not all cases of 
asthma are due to uricacidemia, but nearly all 
eases are benefited by attention to the diet and 
elimination of excess uric acid. 
[171] 



HAY-FEVER 

Of remedies that may be continuously ad- 
ministered to patients who have frequently re- 
curring attacks, two are most constantly used — ■ 
namely, iodid of potassium and arsenic. The 
iodid may be most conveniently given with stra- 
monium, as in the mixture devised by Martin, 
which consists of i^ of a grain of extract of 
stramonium, two grains of extract of licorice, 
three grains of iodid of potassium, and five 
minims of chloric ether. This mixture may be 
given two or three times daily in cases of asthma. 
It possesses two disadvantages, however. The 
stramonium leads, in some cases, to paralysis of 
accommodation, but by diminishing the dose, the 
patient soon ceases to experience discomfort 
from the remedy. If given alone, the iodid must 
be administered in five-grain doses two or three 
times daily, the medicine being discontinued 
from time to time. Arsenic by itself, in doses of 
three minims of the liquor arsenicalis, is a useful 
remedy for continuous administration in asthma, 
and it may be combined with potassium iodid 
(three to five grains) in a mixture. Hydro- 
therapeutic treatment is of use in some cases of 
asthma. The patient should be accustomed to 
gradually colder baths of short duration, with 
douches. 

5. The Use of Serums — Dunbar *s Serum 

The wide recognition of the serum treatment 
of hay-fever by Dunbar, of Hamburg, Germany, 
requires me to quote sufficient of his writings 
that my readers may appreciate the value as 

[172] 



J 



FOEMS OF TEEATMENT 

well as the limitations of his work. To very 
briefly summarize : Dunbar has prepared hay- 
fever antitoxin by inoculation of horses with the 
toxins derived from the albuminoid body found 
in the starch particles of the pollen. The serum 
obtained from the horse is dispensed either in a 
liquid or dry form, and is designed to be applied 
to the mucous membrane of the nose and the eye 
when required. 

His serum has been named Pollantin, and two 
forms are on the market, one prepared from rye 
pollen, especially used for spring and summer 
ihay-fever, or '' rose-cold," and the other, pre- 
pared from ragweed pollen, designed as a 
remedy for hay-fever occurring in the late sum- 
mer and fall. Dunbar thinks that hay-fever is 
the result of a specific poison found in pollens 
and is an albuminoid body — and his antitoxin 
is intended to inhibit, or immunize patients 
against the pollen toxins if used previous to the 
hay-fever season. Its use is also to palliate the 
symptoms in cases where the disorder has 
already made its appearance. Pollantin pro- 
duces a sensation of relief and cool comfort 
when applied to the inflamed mucous membrane 
of the nose or eye. This comfort remains for 
some time, but the relief is variable. 

In 1902, Prof. W. P. Dunbar published,' as an 
appendix to a presentation of the history of our 
knowledge of hay-fever, the opinion, based on 
experiment, that hay-fever is a disease caused 

^Zur Ursache u. spezif. Heilung d. Heufiebers. Verlag 
Oldenbourg, Miinchen, 1903. 

[173] 



HAY-FEVER 

by a poison derived from plants. These toxic 
substances are found in the dust of the blos- 
soms of certain plants. They are present in the 
albumin of the pollen and are septic in nature. 
According to this theory, it would be possible, 
by means of the isolated toxic albumin of the 
pollen, to determine whether or not a given 
disease was ihay-fever. It was also hinted, and 
in a publication that shortly followed," posi- 
tively asserted, that it was possible to produce 
a specific anti-toxin by inoculating animals, e.g., 
rabbits or horses, with the albumin of the pollen. 
It was possible with this antitoxin to neutralize 
the poison of the pollen in vitro so that the latter 
would no longer cause symptoms in hay-fever 
patients. It was also claimed that symptoms 
that had already set in could be overcome by 
the use of the specific antitoxin. 

By means of this timely use of the antitoxin 
the outbreak of the hay-fever symptoms should 
be prevented. As a result of further investiga- 
tion he was later able to prove definitely' that 
by the proper use 'of the antitoxin it would be 
possible to rid patients of their disposition to 
hay-fever, and to immunize them so they could 
dispense with the use of the antitoxin or any 
other therapeutic agent without having to fear 
further attacks. 

*Zur Frage betreffend d. Aetiologie u. spezif . Therapie 
d. Heufiebers. Berl. klin. Woch., 1903, No. 24-26. 

'Zur Ursache u. spezif. Heilung d. Heufiebers II. 
Deutsch. med Woch., 1911, No. 13. 
[174] 



FORMS OF TREATMENT 

Th. Albreeht, the secretary 'of the German 
Hay-Fever Association, designated the appear- 
ance of my first article as a turning-point in the 
history of hay-fever. Other colleagues viewed 
the results of Professor Dunbar's comprehensive 
work with less favor. There were indeed those 
who claimed that he had added nothing new to 
the subject. The opinions exprest by the laity 
were also widely different in character. Some 
were unable to express their thanks in terms 
sufficiently strong, others claimed that the spe- 
cific treatment suggested by him was absolutely 
worthless. An American correspondent wrote 
to him: ''Your stufi: is not worth a tinker's 
dam." In the face of such divergent opinions 
it seems worth while to cast a glance backward 
over the decade that has passed, to determine 
what assertions were right and what opinions 
were incorrect. 

Whether we are right in looking upon hay- 
fever as a product of our modern culture, ap- 
peared to Professor Dunbar to-day, even more 
than it did ten years ago, an open question. In 
the last ten years there has been much published 
concerning hay-fever, not only in the leading 
journals, but also in the lay journals. 

In so far as the latter deals with his work, 
they had not had his cooperation, nor had they 
consulted his wishes. There are to-day many 
hay-fever patients who are absolutely in the 
dark as to the nature of their disease. Even in 
Hamburg, after a scientific ex'hibition at which 
his hay-fever material was shown, many adults 
[175] 



HAY-FEVEE 

<iame to him with, the request that he should 
determine whether or not they had hay-fever. 
He was even more surprized to learn that there 
are to-day physicians who either deny the exist- 
ence of hay-fever or know nothing about it. In 
view of this obtuseness it seemed to liim very 
bold to say that two hundred and fifty years ago 
there was no hay-fever, simply because we have 
no authentic and convincing records from that 
time. The disease may have been very wide- 
spread then. There was missing perhaps only 
the man to notice the periodicity of the disease, 
its dependence upon the seasons of the year, and 
to correctly correlate the facts and draw proper 
conclusions. 

Until ten years before, Dr. Dunbar says no 
one had been able to offer a clear and convinc- 
ing explanation of the cause or nature of hay- 
fever. This is clear from a perusal of the 
literature up to that time. 

Dr. Dunbar, himself a sufferer from hay-fever, 
had the opportunity during many years to test 
the merits of the various hj^otheses concerning 
the cause of the disease. He finally came to the 
conclusion that only the pollen theory could be 
right. In his monograph concerning hay-fever, 
which thus far I have given in his own language 
as above, he described the observations which 
forced him to accept this explanation. For many 
years the attempt to definitely prove the theory 
met with an obstacle which seemed insuperable, 
viz., the impossibility of getting pollen in a pure 
state. In view of the extremely simple method 
[176] 



FOEMS OF TEEATMENT 

of domg this, this fact appeared to him to-day 
a remarkable one. He felt constrained to offer 
the following explanation: 

^'Year after year I consulted with botanists 
as to the best method of getting pollen in large 
quantities. Various methods were suggested to 
me, among others that of spreading large cloths 
over the meadows. I also sucked up into bottles 
large quantities of air in the attempt to get pol- 
len, and attempted many other things. None of 
these methods met with more than moderate 
success, until I finally hit upon the simple pro- 
cedure of shaking blooming plants, for instance 
stocks of wheat, and catching the dust that was 
shaken out. I succeeded better later by taking 
the ears shortly before they began to bloom and 
putting the stocks in water in a warm place. In 
this way I was soon able to gather pollen in 
large quantities, and, more important still, to 
isolate the pollen grains of different plants, free 
from all contaminations, including micro-organ- 
isms. 

*' After having obtained in this way the pollen 
of rye, wheat and ray-grass pollen {Lolium 
perenne), I could at once begin to attempt the 
settlement of important questions. A minimal 
amount of the plant dust when introduced into 
my conjunctival sac, or my nasal passage, caused 
in a very short time most pronounced hay-fever 
symptoms. The same experiment on my lab- 
oratory assistant, who did not have hay-fever, 
had no effect at all. Within a few days I ex- 
tended the scope of my experiments so as to 
[177] 



HAY-FEVER 

include two hay-fever patients, who happened 
to be working in our institution, as well as three 
other assistants who did not have hay-fever. 
The result was always the same. The hay-fever 
patients reacted just as I did. Those who had 
no hay-fever and served as controls were not 
at all affected by the introduction of the pollen. 
These experiments were repeated later on very 
many patients and people without hay-fever, 
invariably with the same results. 

"The next important point that suggested 
itself to me was to determine whether or not this 
toxin was active at other times of the year than 
during the hay-fever period. Formerly, it had 
been urged against the pollen theory that with 
the same pollen which had been active during 
the hay-fever period, no results could be achieved 
at other times of the year. Thus, for instance, 
Sticker was of the opinion that Woodward had 
proved that pollen w^as inactive except during 
the hay-fever period. He, therefore, w^as forced 
to come to the conclusion that for the production 
of an attack there was necessary the disposition 
on the part of the individual and the season of 
the year. The nature of the action of the sea- 
son of the year was explained by some authors 
as a sort of an " Unstimmung, ' ' a sort of spring 
revolution. This explanation appeared to me very 
doubtful, because of the fact that this process 
occurs in European patients in springtime; in 
most American patients, however, in the fall. 

''My experiments on this subject resulted as 
follows: Pollen which had been carefully dried 
[178] 



FOEMS OF TEEATMENT 

soon after gathering was active later at any- 
time of the year. Pollen, however, which I en- 
closed in bottles in its fresh condition under- 
went certain changes, characterized especially 
by the formation of a liquid. 

"Pollen which had been spoiled in this way 
proved later to be inactive. I might add here 
that these observations explained the occurrence 
of sporadic cases of haj^-fever in the winter 
time. Pollen which has found it way into a dry 
room can remain active until the winter season 
— indeed, for many years, as I have shown. 
One blossom which has remained for eleven 
years in the herbarium retained an undi- 
minished activity. Pollen which, on the other 
hand, falls to the ground in the open air, is de- 
stroyed by the first following rain. The fact 
that the pollen is carried down out of the air by 
the rain clearly explains further the remissions 
on certain days which had hitherto been so diffi- 
cult to understand. By means of the isolated 
pollen I had then met those requirements in my 
attempts at an etiologic explanation which I my- 
self have considered necessary. The suspected 
agent, free from all impurities, when applied 
to a hay-fever patient, must produce hay-fever 
invariably, regardless of the season of the year. 
The same agent applied to a normal person must 
have no effect. These requirements had, I say, 
been met by experiment. 

"The grass pollen.is so small that a single one 
can not be seen with the naked eye, yet its striic- 
ture and chemical composition are very compli- 
[179] 



HAY-FEVER 

cated. Many pollen grains are covered with 
iiair-like prickles. Adherents of the pollen 
theory formerly believed that hay-fever was due 
to these prickles. They asserted that hay-fever 
patients were extremely sensitive to the me- 
chanical stimulus of the prickles, and that nor- 
mal individuals were resistant to their action. 
It is true that some of the pollen, which we 
formerly looked upon as the cause of hay-fever, 
had an uneven, prickly surface. Some of the 
first adherents of the pollen theory believe that 
those pollen especially were active whose blos- 
soms had an intense odor. The disease was, ac- 
cordingly, at that time widely called rose-fever, 
linden-fever, and so forth, instead of hay-fever. 
I was able to show that those pollen which most 
often cause hay-fever had a smooth surface. 
This is true of all grass pollen, of which I have 
examined thirty-two varieties. These have also 
no odor. The blossoming of the rose and of 
linden occurs at the same time as that of the 
grasses. In 1902 I was able to completely over- 
throw the belief in the activity of the linden. 
It happened that in that year the blossoming of 
the linden was delayed from three to seven weeks 
in our vicinity, that of the grasses occurring 
■at the regular time. The season for hay-fever 
was probably over at the time that blossoming 
of the linden was at its height, and hay-fever 
patients were able to enjoy the odor of the 
linden without any ill effects. I can well under- 
stand the tenacity with which hay-fever patients 
cling to the belief that the dust of the rose and 
[180] 



FOEMS OF TEEATMENT 

linden causes their symptoms. I myself banned 
from my home every rose and other odorous 
blossom during the hay-fever period, and felt 
certain that my suffering was thereby dimin- 
ished. The relief was not an imaginary one, but 
was due to the fact that at the same time I kept 
my windows carefully closed. 

''At about the time of the blossoming of the 
grasses, the pine {Pinits sylvestris) also begins 
to blossom and produces such a plentiful dust 
that thick clouds of it can at times be seen. 
This is called sulfur rain. I proved, in spite of 
the opposition of many hay-fever patients 
that the dust of this blossom was also of no 
consequence. 

"By such experiments as these and many 
others I was able to prove that only certain 
specific pollen could cause hay-fever. This was 
in direct opposition to Blackley's theory. Other 
pollen, including those possessing sharp prickles, 
were absolutely without effect. 

"The theory as to emanations, odors, ethereal 
oils, and so forth, had still to be considered. On 
opening a vessel that contains much grass pollen 
one gets an odor much like that of honey, which 
proved to be without effect on hay-fever pa- 
tients. The odor of the linden, as well as that 
of the harmless rose, was proved to be without 
effect. There was istill to be considered the 
questions as to the action of the ethereal oils. 
An extract of the oily and waxy portions of the 
pollen, when applied to the conjunctiva and 
nasal mucous membranes in small amounts, 

[181] 



HAY-FEVER 

caused a burning sensation. This was quite 
different, however, from the peculiar sensation 
experienced by hay-fever patients, which is so 
distinctive that nothing can stimulate it. These 
extracts had more effect on normal persons than 
they had on hay-fever patients. The amount of 
these substances with which we come in contact 
in our ordinary walks is so small that they can 
surely not be responsible for any of our un- 
pleasant sensations. 

"Grass pollen is distinguished from that of 
other plants in a marked way by the small rods 
which it contains, which look just like bacteria. 
Patton, in 1877, had already called attention 
to these rods. He believed that after they left 
the pollen grains they possest a movement of 
their own, and he drew the conclusion that they 
constituted the active principle of the pollen. 
He asserted that by reason of their inherent 
motility they found their way into the mucous 
membrane and the circulation and thus caused 
the symptoms of hay-fever. For a time, I also 
believed that these small rods played some part 
in the production of hay-fever. I did not know 
then that they were composed solely of starch, 
but thought they contained albumin. After I 
was able to get hold of great quantities of grass 
pollen I was able to isolate these rods by means 
of repeated centrifugation and washing. I was 
then able to prove that they were absolutely 
innocuous to hay-fever patients. 

" As a result of certain observations, to which 
I shall refer later, I was soon forced to the eon- 
[182] 



FOEMS OF TEEATMENT 

elusion that the active principle of the toxin 
of hay-fever is an albuminous substance. The 
alcoholic precipitate from a saline extract of a 
comparatively small number of pollen grains 
had an intense action on hay-fever patients, but 
none on normal individuals. After I obtained 
large quantities of pollen I began my experi- 
ments with the isolated albumin. Against this 
method of procedure it was claimed that I had 
not been working with a true hay-fever toxin, 
but with a denatured poison. For this claim 
there is no evidence; the critics failed com- 
pletely to show any proof for the correctness of 
their assertions. From a purely scientific view- 
point, it is certainly better to work with the 
isolated toxin than the whole pollen grain or an 
extract from them such as I used at first, before 
I realized that the toxicity was an attribute of 
the albumin alone. 

"Dr. 0. Kammann, who investigated this 
matter at my request,* was able to prove that 
the albumin fraction contains the toxin and 
that the globulin fraction is entirely inactive. 

''Having determined that the albumin of the 
pollen is the specific cause of hay-fever, it was 
possible now to carry out my experiments along 
quantitative lines. It is possible to extract the 
albumin from the pollen by means of saline solu- 
tions of proper strength and then to precipitate 
it with alcohol or to obtain it by dialysis, and 

* Kammann : Zur Kenntnis d. Eoggen-Pollens u. des 
darin enthaltenen Heufiebergiftee. Beitrage z. Chem. 
Physiol, u. Pathol., 1904, Bd. V, Heft. 7-8, S. 346. 
[183] 



HAY-FEVEE 

then dry it. In this condition it retains its ac- 
tivity for many years. 

' ' The experiments which I had done np to this 
time on hay-fever patients had not conformed to 
the natural process. In order to conform to 
these more closely I performed the following 
experiment: A hay-fever patient and a normal 
individual took their places in a large glass cab- 
inet in which rye pollen had been distributed. 
The hay-fever patient took sick, the other re- 
mained well. It was not determined by this 
experiment how much of the pollen had been 
taken up by the hay-fever patient. The ques- 
tion as to whether or not enough pollen was 
present in the air during the hay-fever season to 
cause the symptoms had not been satisfactorily 
settled. Blackley {vide supra) had already 
made attempts to settle this question by means 
of a method worked out by Phoebus. He had 
carefully counted at different periods of the 
years the pollen which gathered on glass plates, 
whose surface had been covered with glycerin. 
My coworkers, especially Liefmann,'' found that 
in the heart of Hamburg, while hay-fever was 
at its height, 250 pollen grains accumulated on 
a surface of one square centimeter during 
twenty-four hours, i.e., 25,000 to the square 
meter. It was established that with the first 
appearance of the pollen in the air the patient 

''Liefmann: Ein Beitrag zur Frage nach d. aetiologi- 
schen Bedeutung gewisser Pflanken' pollenkoerner fuer 
d. Heufieber. Zeitschr. f. Hjg. u. Infectionskrankheiten, 
1904, Bd. 47, p. 153. 

[184] 



FOEMS OF TEEATMENT 

began to complain of an itching at the inner 
canthus of the eye; his suffering became more 
intense in direct proportion to the quantity of 
pollen in the air. On rainy days no pollen ac- 
cumulated on the glass plates, altho they were 
protected from the rain. Early in June the 
pollen of the grasses far exceeded those of other 
plants in numbers, and from about the third 
week in July grew gradually less, so that at 
the end of July, or the beginning of August, 
only a few stray grains were found. Thus can 
be explained the periodicity of the course of 
hay-fever and also the occurrence of sporadic 
cases after the hay-fever season is over. There 
was still no certain method of predicting quanti- 
tatively the action of the pollen. Dr. 0. Kam- 
mann had shown that the organic portion of the 
pollen of the grasses is about 40 per cent. 
albumin. He had shown further that about 
20,000,000 rye pollen weighed one gram. By 
means of these figures we could compute the 
amount of toxin in a single pollen. By means 
of a solution of known strength of the poisonous 
albumin of the pollen, it could be determined 
how many pollen grains were necessary in any 
given case to produce mild, moderately severe, 
or severe symptoms. It was evident that differ- 
ent patients were susceptible in varying degre^-s. 
A concentrated solution introduced into the con- 
junctiva or nose of a normal individual causes 
no symptoms. The majority of hay-fever pa- 
tients were stimulated by one drop (1-20 to 1-30 
cm.) of a solution of 1 to 20,000 or 1 to 30,000. 
[185] 



HAY-FEVEB 

There were patients, however, who responded 
to one drop of a solution diluted a million times, 
the equivalent of the amount of albumin con- 
tained in one to three pollen grains. 

' ' Lief mann constructed an aeroscope by means 
of which he was able to determine how much 
pollen was taken in with each breath. In the 
neighborhood of a field of rye one inhales with 
each breath two or three pollen grains; in the 
middle of a large city he found that in every 
cubic meter of air there were about three hun- 
dred and eight. 

''Thus in this way questions as to the quan- 
titative relationship of the pollen to the attack 
were satisfactorily answered. By means of these 
experiments it had been plainly shown that the 
albumin of the pollen of certain plants, es- 
pecially that of all grasses, is to be looked upon 
as the active cause of hay-fever. With my co- 
workers I examined the pollen of 106 plants, 
and found them all without any action, altho 
I had examined such pollen which had been 
considered capable of producing hay-fever. In 
addition to the pollen, I had been informed that 
in China at the time of the blossoming of Ligus- 
trum vulgare a disease very much like hay- 
fever was prevalent. I examined the pollen of 
this plant and found it active. In Southwest 
Africa, when the grasses blossom, conditions 
like hay-fever prevail, especially among the 
half-breeds. One European had to forsake 
Africa at this time on account of his intense 
suffering. In Europe he remained perfectly 
[186] 



FORMS OF TREATMENT 

well. On examination it was found that he did 
not react to the grass pollen. In Africa, how- 
ever, at this time, the acacia blossoms and it has 
been looked upon as the cause of the condition. 
This patient was unaffected by the pollen of two 
different species of acacia. I am in hopes that 
experiments which we have since then set on foot 
will explain this disease to us. In addition to 
the thirty varieties of graminacege and cyper- 
aceae, I have found the pollen of the following 
plants active: swamp-pink {Lonicera capri- 
folium), lily-of-the-valley {Convallaria majalis), 
hairy Solomon's seal {Polygonatum multi- 
forum), CEnothera biennis, rape {Brassica 
napus), and spinach {Spinacia oleracea). 

"Of special importance is the autumnal 
catarrh, which occurs in the United States of 
America, beginning early in September and last- 
ing about six weeks. This autumnal catarrh is 
much more common in the United States than 
the vernal catarrh. I have had the opportunity 
of examining a large number of American hay- 
fever patients, and was able to establish the 
fact that those patients who only suffer in the 
fall do not react at all to the albumin of the 
grass pollen. They do react, however, regularly 
to the albumin of the pollen of goldeurod 
(Solidago) and of ragwood (Amhrosia) . I have 
examined a large number of species of both 
these plants and they were all active. These 
patients also react to the pollen of the chrysan- 
themum and the other asters. Those American 
patients who suffer only from spring catarrh, 
E187] 



HAY-FEVEE 

not from the autumnal type, react only to the 
grass pollen, not to that of the goldenrod or the 
ragweed. A third group of patients suffer from 
about the middle of May until early in Novem- 
ber with a hay-fever-like affection. These un- 
fortunates react both to the grass pollen and to 
the active agent of the autumnal catarrh. 
Goldenrod and ragweed are very widespread 
in the United States. They are found not only 
on meadows, fields, roads and along edges of 
woods, but grow in the midst of cities in 
neglected places. In Europe they do not occur 
naturally, indeed the goldenrod can with diffi- 
culty be made to blossom there. The pollen of 
goldenrod, however, is not scattered as easily 
as that of the ragweed. All attempts to grow 
ragweed in this country failed until 1911. In 
this year, which was extremely hot and dry, I 
succeeded for the first time. These facts serve 
as further important supports for the pollen 
theory. There were, however, still many ques- 
tions to be settled before all this mysterious 
phenomena which characterize hay-fever could 
be explained. 

''One very important question, that of indi- 
vidual predisposition, I have only lightly 
touched upon. It is clear that all people, in- 
cluding the inhabitants of large cities, are at 
certain times of the year exposed to the pollen 
of many plants, which settle on their skin, con- 
junctiva, are inhaled into the nose, and taken 
up into the mouth. By far the largest part of 
these individuals are unaffected by the pollen, 

[188] 



FOEMS OF TEEATMENT 

only a very small percentage take sick. The 
poisonous albumin of the pollen is a substance, 
therefore, which is innocuous to most people, 
and is only active in those cases in whijh there 
is a special susceptibility. In other words, hay- 
fever requires an individual predisposition. 
This personal predisposition is present for the 
well-known poisons of the pharmacopoeia, either 
not at all or at most in very slight degree. In 
the case of the infectious diseases it is much 
more evident. If, for instance, the cholera or 
typhoid bacillus is spread through a city by 
means of the water supply, only a small percent- 
age of the inhabitants are unaffected. This can 
be explained on the theory that the cholera or- 
ganism does not find in most individuals those 
conditions which are necessary to its existence 
and growth. The fact that only about half of 
the cholera patients die can be explained by 
similar quantitative differences. I do not know 
of another instance of a substance absolutely 
inactive as far as a part of the population is 
concerned, but a very virulent poison for others. 
The individual predisposition in a case of hay- 
fever must be of a peculiar sort. It might be 
explained that the hay-fever poison enters the 
circulation of some people (hay-fever patients) 
and not of others. That this is the case I could 
prove by the demonstration of antibodies in the 
blood of the hay-fever patients. I shall return 
to this subject later. Here it is sufficient to say 
that these specific substances could be found 
only at the close of the hay-fever period; six 

[189] 



HAY-FEVER 

months later they had disappeared. In normal 
individuals they could at no time be demon- 
strated. The gradual disappearance of the im- 
mune bodies is easily explained. We know 
from animal experiment that these substances 
appear a certain time after infection, gradually 
to disappear again. At first blush the demonstra- 
tion of immune bodies in the blood of hay-fever 
patients would seem to be a sufficient explana- 
tion of the hay-fever predisposition. Close study 
makes this seem uncertain. 

On continuing the experiments I found that 
these immune bodies were not present in all 
patients, indeed, in the same patient I could not 
find them in some cases two years in succession. 
The following objection to this explanation was 
even stronger: A colleague of mine, disposed 
to hay-fever, who had helped me for many years, 
allowed himself to be injected with a solution of 
pollen albumin. One half -hour after the injec- 
tion marked symptoms appeared in the eyes, 
nose, and mouth. The patient experienced pains 
in the chest, expectorated a tenacious, mucoid 
sputum, and perspired freely. The respiration 
became rapid and difficult, the pulse-rate was 
accelerated, and the voice grew weak. After 
fifty minutes there was a flat, urticarial erup- 
tion over the whole body. After twenty-four 
hours all the results of the injection had not yet 
disappeared. At the site of the injection there 
was a marked swelling, which persisted for 
five days. 

'' Injection of hay-fever toxin caused the same 

[190] 



FOEMS OF TEEATMENT 

symptoms in me. A colleague who did not suffer 
with hay-fever reacted to the same dose with a 
small, almost imperceptible swelling at the site 
of the injection. Pollen albumin was, in other 
words, not toxic for him when introduced under 
the skin. Hundreds of experiments have proved 
to us that pollen albumin is not a poison in the 
ordinary sense of the word, and that even when 
introduced into the circulation it is inactive. 
Not only is the skin of hay-fever patients per- 
meable, for the hay-fever poison in varying de- 
grees, but it also reacts to the toxin in different 
ways in different patients. In some cases when 
a solution of pollen albumin is placed on the 
skin, there occurs within a few minutes an ery- 
thema. If, on the other hand, a patient is very 
susceptible to hay-fever, the skin may show ab- 
solutely no reaction when brought in contact 
with the toxin. These results may be of value 
in the study of individual predisposition, since 
they enable us to throw some light upon the 
question as to whether or not hay-fever is to be 
looked upon as a result of hypersensitiveness. 

*'In the first place, statistics have definitely 
proved that hay-fever has no relation to any con- 
stitutional disease, — for instance, gout; that, in- 
deed, only a very small percentage of hay-fever 
patients are gouty. It is very commonly be- 
lieved that hay-fever is due to some anomaly or 
stopping up of the upper air-passages. A local 
disease of the trigeminus is assumed by some, 
with a resulting sensitiveness on the part of cer- 
tain mucous membranes. The falsity of these 
[191] 



HAY-FEVER 

conceptions is clear from the experiments 
cited above. Not only does the whole skin sur- 
face of many patients react to the poison, but 
subcutaneous infection is followed by character- 
istic effects. By showing that the anal mucous 
membrane of hay-fever patients reacts to the 
pollen toxin, I believe that all those hypotheses, 
which assume only a local sensitiveness on the 
part of the cranial nerves, or the capital mucous 
membrane, is robbed of support. Suggestion, as 
we have seen, plays a large part in the attempts 
to explain hay-fever predisposition. I can treat 
this question together with that of the role of 
specific odors of flowers, cats, dogs, etc. Two 
colorless odorless solutions were prepared, and a 
drop from one of them was placed on the mucous 
membrane of the eye and nose of a large number 
of hay-fever patients. Some reacted, others did 
not. None of them knew what sort of a solution 
was being used. The applications were then 
made in a different way, each patient receiving 
a drop of the solution which had not been used 
in his case before. Those who had reacted the 
first time did not do so the second. The one 
solution was physiologic salt, the other pollen 
albumin. None of the patients reacted to the 
saline, all reacted to the other solution. In the 
course of many years I repeated these experi- 
ments with many variations. In the place of 
the salt solution I used solution of albumin from 
inactive pollen. The results were always the 
same. In the face of such results, he who would 
explain hay-fever on the ground of suggestion, 
[192] 



FOEMS OF TREATMENT 

simply ignores all the facts to the contrary, and 
his opinion does not deserve serious considera- 
tion. 

"Hay-fever is looked upon as a result of an 
advanced culture and civilization. It happens 
that there are very few hay-fever patients in 
the laboring class, and that the Anglo-Saxon 
races, especially the Germans, English, and 
Americans, furnish the largest number of such 
patients. That hay-fever does at times occur 
among the Romans and other nations, I am able 
to gather from correspondence that I have had 
with inhabitants of such countries. In St. Louis 
I met an elevator boy who had hay-fever. Among 
the Anglo-Saxons the disease is found most often 
among professional men. Men appear to be 
twice as susceptible as women. It is often 
claimed that hay-fever follows a period of strenu- 
ous mental work, or of excitement, as, for 
instance, after examination, or in officers after 
maneuvers. Hay-fever has often been shown to 
be hereditary. Most frequently, however, a 
severe attack of influenza has left hay-fever in 
its wake. Other causes, as, for instance, a diffi- 
cult labor, are asserted by patients to have been 
the exciting cause of their hay-fever attacks. 
May we conclude from all these facts that hay- 
fever is the result of a disturbance of the central 
nervous system? 

''It was formerly believed that all hay-fever 
patients were very nervous and excitable. This 
is certainly not universally true. If we are 
indeed dealing with a severe abnormality of the 

[193] 



HAT-FEVER 

central nervous system this, in most instances, 
makes itself felt only in a hay-fever predisposi- 
tion. Hundreds of hay-fever patients have writ- 
ten me that except during the season they are 
altogether well, and I have found among hay- 
fever patients many with phlegmatic disposi- 
tions. Those idiosyncrasies which resemble hay- 
fever in a way, as, for instance, susceptibility to 
strawberries, crawfish, iodin, antipyrin, bromids 
and the salts of quinin, are to-day explained on 
the ground of anaphylaxis. 

''Th. Albrecht declares that ten years ago 
every physician had his own theory concerning 
the treatment of hay-fever. And I may add 
from my own experience that every patient also 
had his own method of treatment, which was, as 
a rule, very complicated. From my records it 
is very evident that many patients had ten or 
more hay-fever remedies, which they used either 
separately or together. A hay-fever patient 
takes up at once every new remedy that appears 
and enthusiastically recommends it to others. 
As a rule, he learns of the new remedy near the 
end of the hay-fever season, and while he is using 
it his troubles disappear and he attributes his 
relief to the remedy he has been using. In the 
following spring he is undeceived. In this way 
one hay-fever remedy after another is consigned 
to oblivion only to reappear later under a differ- 
ent name. The only remedies that have survived 
for any length of time are those with narcotic 
effects, as cocain, adrenalin, anesthesin, morphin, 
etc. Concerning the danger connected with the 
[194] 



FORMS OF TREATMENT 

use of these narcotics, it is surely not necessary 
to say a word. In addition, adrenalin and 
anesthesin and the remedies prepared from them 
cause in many cases a sensation that is much 
more annoying and unpleasant than hay-fever 
itself. I, myself, have tested all the hay-fever 
remedies on which I could lay my hands within 
the last ten years. With no one of them did I 
accomplish a beneficial result. There was in- 
deed no reason to suppose that the remedy could 
accomplish the things that were claimed for it. 
It is easy to gather the same opinion if one 
reads the thousands or more hay-fever histories 
that I have in my possession. I have called 
attention above to the fact that on purely theo- 
retical grounds nothing was to be expected from 
these preparations, and that chance had not 
put into our hands a chemical preparation that 
was effective. Every physician must warn his 
patients against the use of narcotics. I shall, 
therefore, not consider these remedies and meth- 
ods of treatment that belong to this category. 

*'In the thousands or more histories which I 
have been able to read, cauterization, burning, 
chiseling, and sawing in the nose play a large 
part. 

''It has been shown that the active albumin 
pollen is a substance of such marked specificity 
that the albumin which causes hay-fever symp- 
toms in one patient (pollen of the grasses in 
Europeans) is entirely inactive in other patients 
(those with autumnal catarrh). On the other 
hand, the toxin of the ragweed has absolutely 

[195] 



HAY-FEVER 

no effect on the European patients. By means 
of the complement deviation method I could 
prove that this specificity could be shown in 
the hemolytic properties of the different al- 
bumins, the albumin of the grass pollen reacting 
altogether differently from that ot goldenrod and 
ragweed. In view of this state of affairs, it is 
not to be hoped that chance would furnish us 
a chemical substance that would either neutral- 
ize or render inactive the pollen albumin, or 
overcome the individual predisposition, which, 
as we have seen, is also strictly specific. I have 
come to the conclusion that we can accomplish 
our end in three ways only. 

"First, by finding localities where the specific 
cause does not occur; second, by protecting the 
eyes, nose and mouth of the patient from the 
pollen; third, by active immunization against 
the toxin, or the use of a specific antitoxin. 

' ' The first method is yearly employed by many 
patients with success. The second method is also 
successful. Hay-fever patients are free from 
symptoms in regions in which a specific pollen 
does not occur. This was to be expected from 
what we have learned about the cause of the 
disease. Thus many patients find relief on the 
seashore, in islands, and in barren mountain- 
ous districts. In Germany they go to Heligo- 
land. In the United States they retire to Fire 
Island, Long Beach, the White Mountains, 
Green Mountains, or Adirondack Mountains dur- 
ing the hay-fever season. 

''AH my attempts of many years to get rid 
[196] 



FORMS OF TREATMENT 

of the irritating contents of the horse serum 
have been in vain. As early as 1905, I realized 
that this would be so, for I proved then that 
the irritating substance (as I then called the ana- 
phylactic agent) v;as bound to the euglobulin 
of the horse serum as was also the antitoxin 
itself. If the euglobulin is destroyed the anti- 
toxin is at the same time rendered useless. I 
have been able to help patients who have become 
anaphylactic in two ways : First, by the use of 
pollantin R., and the suggestion to use this di- 
luted serum only before the occurrence of the 
hay-fever attack, in the very smallest doses, and 
if possible only once daily. Patients who followed 
these directions have informed me that pollantin 
R. did not irritate them at first, altho it did so 
later. The irritation was, however, not severe 
and disappeared within ten to thirty minutes. 
After this the patient was free from hay-fever 
attacks for one or more days. Secondly, I have 
taken advantage of the fact that horse serum 
anaphylaxis is in most cases specific, but does 
not appear to me to be always so. I have seen 
instances in which during the development of a 
hypersensitiveness to one animal serum, patients 
were rendered anaphylactic to the sera of other 
animals also. This does not, however, happen 
often. I have, therefore, administered to pa- 
tients who could no longer stand pollantin R., 
a very active rabbit serum with good results. It 
was not only possible to ward off attacks with 
this serum, but also to protect patients from 
further attacks during the hay-fever season. 
[197] 



HAY-FEVER 

These results ^appear to me to support the opin- 
ion, which I exprest years ago, viz., that the re- 
action to the antitoxin, and with it the tendency 
toward definite immunization, is directly pro- 
portional to the degree to which anaphylaxis 
toward animal serum develops. Patients who 
have become anaphylactic get along with much 
smaller doses of antitoxin than other patients, 
and have, I believe, a better chance to effectually 
overcome their hay-fever predisposition. 

''This is the goal toward which we must 
strive. I know of many hay-fever patients, some 
of whom had attacks of the worst kind, who 
were entirely free after the use of pollantin for 
a very short time. I consider these people per- 
manently cured, and so exprest myself in an 
article last year. A rhinologist interested in 
hay-fever wrote to me that he could not under- 
stand these successes, and that he and his col- 
league had never been able to obtain such re- 
sults. He wrote further that my successful 
experiences were in marked contrast to the ex- 
perienced German Hay-Fever Association. In 
answer to such communications I have placed 
my material in the hands of the secretary of this 
Association, Dr. Th. Albrecht. I was very much 
pleased to learn as a result that Dr. Albrecht 
had been able to cure and successfully immunize 
patients by means of pollantin. In a recent 
publication. Dr. Albrecht reported twelve cases 
in which, after the use of pollantin for a short 
time, there resulted either a complete cure or 
at least a marked improvement. These observa- 

[198] 



FOEMS OF TEEATMENT 

tions are, of course, of intense interest to me. 
I would ask all colleagues who have made similar 
observations to be kind enough to communicate 
them to me. I have only been strengthened in 
my former opinion that by means of a mixed 
passive and active immunization a permanent 
cure of hay-fever can be accomplished." 

6. Frequent Causes and the Treatment op 
Seasonal Hay-Fever* 

By Chandler Walker, M.D. 

BOSTON 

Although John Bostock,* in 1819, first de- 
scribed the symptom complex of hay-fever, it 
was not until 1873 that Blackley' determined 
the real cause of the symptoms, namely, the 
pollen of plants. Curtis,* in 1900, was the first 
to attempt to produce active immunity or to treat 
the condition; he used extracts of the whole 
plant. Since Dunbar,* in 1905, was the first to 

* From the medical clinic of the Peter Bent Brigham 
Hospital. Eeprinted from the ''Archives of Internal 
Medicine," July, 1921, Vol. XXVIII, pp. 71-118. Copy- 
right, 1921, American Medical Association, Chicago. 

*Bostock, J.: Case of Periodical Affection of the 
Eyes and Chest, Med. Chir. Tr., Lond. 10:161, 1819. 

'Blackley, C. H. : Experimental Researches on the 
Causes and Nature of Catarrhus Aestivus (Hay -Fever or 
Hay Asthma), London 7:202, 1873. 

' Curtis, H. H. : The Immunizing Cure of Hay 
Fever, Med. News 77:16 (July 7), 1900. 
[199] 



HAY-FEVEE 

employ extracts of the plant pollen, the modern 
treatment of hay-fever was really begun by him. 
During the past ten years reports on the treat- 
ment of hay-fever have been too numerous to 
justify reference to all of them in this paper, 
but the work of Noon, Freeman, Koessler, Cooke, 
Scheppegrell, Goodale, Selfridge and possibly 
of others justify the mention of their names 
since it is these who have done most toward estab- 
lishing the treatment of seasonal hay-fever. 

Notwithstanding the number of papers on the 
subject, there is a paucity of specificity as re- 
gards the pollens that actually cause hay-fever, 
and, likewise, the treatment of the condition has 
been stated too often in a general way. As a 
result, there would seem to be as many different 
pollens actually causing hay-fever and as many 
different ways of treating hay-fever as there have 
been investigators. A natural result was that 
commercial houses have put on the market pollen 
preparations consisting of mixtures of the various 
pollens that prevailed at definite seasons, ?nd 
these mixtures were used by the medical profes- 
sion all over the country. In -other words, 
neither the physician nor the commercial house 
have been concerned as to whether any particular 
pollen was indigenous and caused hay-fever in 
one locality to the exclusion of other pollens in 
other localities, and the physician would not or 
could not determine by tests which of the prevail- 

* Dunbar, W. P.: Berl. klin. Wchnsclir. 17:797, 877, 
915, 942, 1237, 1905; Deutsch. med. Wchnschr. 32:578, 
1911. 

[200] 



FOEMS OF TEEATMENT 

ing pollens was the actual cause of symptoms; 
the pollen mixtures were used hit or miss. From 
the practical standpoint, the results from such 
treatment could not be as satisfactory as would 
be the case if the patient were treated by the 
pollens to which he was actually exposed and 
to which he was most sensitive. Therefore, the 
excuse for publishing the present paper in con- 
siderable detail is to help clarify the present 
status of the treatment of seasonal hay-fever as 
regards patients living in the New England 
States, and it hoped that other investigators in 
the same and in other localities will be stimu- 
lated to detail their investigations. It is only 
by such detailed reports that it will be possible 
to learn the prevailing causative pollens in vari- 
ous localities and the best method of treatment. 

After a description of the methods used by me 
in testing and treating hay-fever patients, this 
paper will consist of a series of tables. Table 1 
presents those patients who were treated with 
ragweed pollen only one year; Table 2, patients 
treated with grass pollen only one year ; Table 3, 
patients who had insufficient treatment with rag- 
weed and with grass pollen; Table 4, patients 
treated two years in succession with ragweed 
pollen; Table 5, patients treated two years in 
succession with grass pollen; Table 6, patients 
treated three successive years with ragweed 
pollen; Table 7, those treated three successive 
years with grass pollen, and Table 8, those 
treated four successive years with ragweed 
pollen. In all of these tables the patients were 
[201] 



HAY-FEVEE 

treated preseasonally, thereby attempting to pre- 
vent symptoms. Table 9 presents patients who 
were treated during the season with grass pollen ; 
Table 10, those treated during the season with 
ragweed pollen, and Table 11, patients treated 
during the season with bacterial vaccines. In 
these tables the patients were treated during the 
season, thereby attempting to relieve symptoms. 
Table 12 presents patients treated both preceding 
and during the season. The pollens of trees 
and pollens other than those already mentioned 
will be diseust as possible causes of hay-fever. 
Finally, other parts of plants, animal emanations, 
foods, bacteria and olfactory irritants will be 
diseust as causes of seasonal hay-fever. 

The cutaneous or skin test, which has proven 
satisfactory to me," was employed to determine 
the sensitivity of the patients to the various 
pollens. A number of small cuts, each about an 
eighth of an inch long, are made on the fl^^or 
surfaces of the forearm. These cuts are made 
with a sharp scalpel, but are not deep enough to 
draw blood, altho they do penetrate the 
skin. On each cut is placed a pollen and to it 
is added a drop of tenth normal sodium hydroxid 
solution to dissolve the pollen protein and to 
permit of its rapid absorption. Instead of using 
the whole pollen, a concentrated solution of 
pollen protein or extract may be used without 

•Walker, I. C, and Adkinson, J.: A Comparison Be- 
tween the Cutaneous and the Intradermal Tests in the 
Sensitization of Asthmatic and Hay Fever Patients, J. 
U. Ef search 37:287, 1917. 

[202] 



FOEMS OF TEEATMENT 

the addition of sodium hydroxid. At the end 
of half an hour the pollens are washed off and 
the reactions are noted, always comparing the 
inoculated cuts with normal controls on which 
no pollen was placed. A positive reaction con- 
sists of a raised white elevation or urticarial 
wheal surrounding the cut. The smallest reac- 
tion that we consider positive must measure 0.5 
cm. in diameter. All larger reactions are noted 
by a series of plus marks ; any smaller reaction is 
called doubtful. The method of obtaining pollen 
from the flower has been outlined in Study 11.' 

Having determined by these tests which pol- 
lens give a positive reaction, before a patient can 
be treated with the pollen it is necessary to know 
how sensitive that patient is to the pollen ; there- 
fore, different strengths of solutions of the pollen 
protein are tested in a similar manner. These 
solutions are made as follows: To 0.5 gm. of 
the dry pollen is added 44 c.e. of sterile physi- 
ologic sodium chlorid solution, and the mixture 
is shaken thoroughly at frequent intervals for 
twenty-four hours, after which enough absolute 
alcohol (6 c.c.) is added to the mixture to make 
the alcoholic content 12 per cent. Again, the 
mixture is thoroughly shaken at frequent inter- 
vals for twenty-four hours, after which it is cen- 
trifugalized at high speed and the supernatant 
fluid is pipetted off and saved. This super- 
natant fluid, therefore, consists of the pollen 

•Walker, I. C. : Studies on the Sensitization of Pa- 
tients with Bronchial Asthma to the Various Pollens, 
J. M. Research 36:237, 1917. 

[203] 



HAY-FEVER 

protein dissolved in a 12 per cent, alcoholic physi- 
ologic sodium chlorid solution and it represents, 
by weight, 1 part pollen to 100 parts solvent. 
This 1 : 100 solution is used as stock, and from 
it other dilutions, 1 500, 1 : 1,000, 1 : 5,000 and 
1 : 10,000 are made, using a 12 per cent, alcoholic 
physiologic sodium chlorid solution as a diluent. 
These solutions are used not only for the skin 
tests but for treatment, and with the addition of 
a small crystal of thymol they keep for many 
months in a cool place. 

Method of Treating Preseasonally with the 
Pollen Extracts Follows. — The first treatment 
consists of from 0.1 to 0.2 c.c, of that dilution 
next higher than the one which gave a positive 
skin test, or, in other words, the first dose is 
0.1 c.c. or 0.2 c.c. of the strongest dilution which 
fa led to give any skin reaction whatever, no 
matter how slight. With our pollen extracts 
the majority of patients whom we treated gave a 
more or less positive reaction with the 1 : 5,000 
dilution, therefore, the first treatment consisted 
of 0.1 c.c. or 0.2 c.c. of the 1 : 10,000 dilution. 
Treatments were given subcutaneously once a 
week, and each week the amount of the extract 
was gradually increased, so that as the treatment 
progressed, stronger and stronger dilutions were 
used, until one or more doses of the 1 : 100 di- 
lution were given. As an example, I will give 
what I have found by experimentation to be the 
best outline of treatment for a patient who gives 
a more or less positive skin test with a 1 : 5,000 
dilution of pollen extract ; 1 : 10,000, give 0.15 
[204] 



FOEMS OF TEEATMENT 

c.c. ; 1 : 5,000, give 0.15 c.c, 0.25 c.c, 0.35 c.c, 
0.45 c.c. ; 1 : 1,000, give 0.15 c.c, 0.25 c.c. ; 1 : 500, 
give 0.15 c.c, 0.25 c.c, 0.35 cc, 0.45 c.c. ; 1 : 100, 
give 0.15 c.c, 0.2 cc, 0.25 cc Each dose was 
given preferably at weekly intervals and never 
oftener than once every five days 

This schedule of treatment calls for fourteen 
inoculations ; however, for some reason or other, 
modifications frequently have to be used. An 
occasional patient is so sensitive to the pollen 
that a 1 : 10,000 dilution gives a slight reaction, 
thus necessitating an initial dose of 0.15 cc of 
1:20,000 followed by possibly two doses of 
1 : 10,000. Often it happens that a patient has 
considerable local or general reaction following 
some one treatment in the schedule, thus neces- 
sitating the repetition of that particular dose 
before the next increase may be given. More 
often the patient presents himself for treatment 
too late to complete the scheduled series of treat- 
ments before the onset of pollination so that for 
preseasonal treatment alone, some of the final 
treatments in the schedule must be omitted. This 
schedule is often modified purposely with certain 
individual cases. For instance, in some cases 
the second treatment with the 1 : 1,000 dilution, 
namely, 0.25 c.c, is omitted, and in some cases 
instead of giving 0.15 cc of the 1 : 100 dilution, 
when this happens to be the final treatment that 
the patient is to receive because of onset of 
pollination, a fifth treatment with the 1 : 500 di- 
lution, namely, 0.55 c.c, is often substituted, and 
even a sixth treatment with the 1 : 500 dilution, 
[205] 



HAY-FEVER 

namely, 0.65 c.c, is sometimes given. These 
larger doses of 1 : 500 approximate the amount 
of protein in 0.15 and 0.2 c.c. of the 1 : 100 di- 
lution, therefore, the fifth and sixth treatment 
with the 1 : 500 dilution, as outlined, is practi- 
cally the equivalent of giving 0.15 c.c. and 0.2 c.c. 
of the 1:100 dilution. Since by far the great 
majority of patients are treated from three to 
five times with the 1 : 500 dilution, and since this 
number of treatments has given fairly satisfac- 
tory results, I consider this number of treat- 
ments, which consists usually of a total of ten, 
as worth giving, although a continuance of the 
schedule beyond three doses of the 1 : 500 dilution 
is most desirable, and giving less than three 
treatments with the 1 : 500 dilution is undesira- 
ble. Tables 1 and 2 will illustrate the results 
obtained from giving three or more treatments 
with the 1 : 500 dilution, and Table 3 will illus- 
trate the results obtained from giving less than 
three treatments with the 1 : 500 dilution. 

Since in the New England States the majority 
of patients have the first hay-fever symptoms 
between Aug. 10 and 20, during which time the 
compositae, chiefly ragweed, begin to pollinate, 
in order to complete the above schedule just 
previous to the onset of symptoms and pollina- 
tion, patients must begin treatment between the 
last week in April and the first two weeks in May. 
Beginning treatment the first week in June will 
permit of giving from three to five treatments 
with the 1 : 500 dilution. Likewise, since the 
early type of hay-fever, or so-called rose cold, 

[206] 



FOEMS OF TREATMENT 

which, is usually caused by the grasses, begins 
the last few days of May or the first of June, 
treatment for this type of hay-fever should begin 
about the first of March, and the starting of 
treatment as late as the first of April will not 
permit of more than three or four treatments 
with the 1 : 500 dilution, according to the sched- 
ule outlined. Naturally, in localities outside of 
New England, these seasons would differ, and 
the beginning of treatment consequently would 
vary, also the causative pollen must differ. 

Before Table 1 may be discust, attention 
should be called to the following facts: In the 
New England States ragweed (ambrosia arte- 
misifolia, or dwarf ragweed) is not the only 
plant that pollinates during August and Septem- 
ber, nor is it the only pollen to which individuals 
are exposed or with which patients were tested. 
Most of the compositae, such as goldenrod, sun- 
flower, golden-glow and aster, pollinate during 
August and September; daisy pollinates during 
June and July, and dandelion in the early 
spring; giant ragweed is rarely encountered in 
the New England States. In order to simplify 
the table, and because in my experience pollens 
other than ragweed rarely, if ever, are the chief 
cause of symptoms during the late hay-fever sea- 
son, only ragweed is mentioned in the table al- 
though tests were made with the other pollens. 
During the years 1917, 1918, and 1919 all of the 
patients in Table 1 were with goldenrod 
and daisy, and the majority were tested with 
golden-glow and sunflower. During 1920 many 
[207] 



HAY-FEVER 

of the patients were tested with these pollens. 
One hundred and twenty patients in Table 1 
were tested with the pollens of daisy and golden- 
rod, and 100 were also tested with the pollen of 
sunflower and golden-glow. Fifty per cent, of 
those tested with golden-glow and with sunflower 
gave a positive reaction with the whole pollen, 
but none of these gave a reaction with a 1 : 100 
dilution of the pollen; the other 50 per cent, 
failed to react with the whole pollen. Therefore, 
it may safely be stated that the pollens of golden- 
glow and sunflower are not primarily causes of 
hay-fever in New England. Of those tested with 
daisy pollen, 65.5 per cent, failed to react to a 
1 : 100 dilution of daisy pollen ; 21 per cent, did 
react to the whole pollen but not to a 1 : 500 di- 
lution; 10 per cent, reacted more or less posi- 
tively to a 1 : 500 dilution of the pollen, and only 
3.5 per cent, reacted to as high a dilution as 
1 : 1,000. Therefore, in comparison with rag- 
weed, in only 3.5 per cent, could one consider 
that daisy might be a cause of hay-fever as 
judged by tests, but it should be borne in mind 
that daisy pollinates during June and July and 
has finished pollination before ragweed begins, 
therefore daisy cannot complicate the causes of 
August and September hay-fever. Of the 120 
patients in Table 1 who were tested with golden- 
rod pollen, 78.5 per cent, failed to react with a 
1 : 100 dilution of the pollen ; 10 per cent, did not 
react to a 1 : 500 dilution of the pollen ; 8.25 per 
cent, did react more or less to a 1 : 500 dilution, 
and 3.25 per cent, reacted to a 1 : 1,000 dilution 
[208] 



TABLE 1.— PRESEASONAL TESTS AND TREATMENT 

WITH RAGWEED POLLEN 
G = Good. F = Fair. N = None. 



Patient 



Age 

of 

Onset 



Dura- 
tion 



Tests 

Before 

Treatment 



Number 

Treatments 

with 

Final 

Dilution 



Tests 

at End 

of 
Treat- 
ment 



Result 

of 
Treat- 
nvent* 



13 

14 

15 

16 

17 

18 

19 

21 

20 

22 

23 

24 

25 

25 

27 

28 

29 

30 

31 

32 

33 

34 

35 

35a 

36 

36a 

37 

38 

39 

40 

41 



42 
8 
44 
18 
17 
26 
24 
43 
30 
43 
10 
1 



Season 1917 
1-1,000 ± 
1-5.000 ± 
1-1.000-1- 
1-5.000 ± 
1-5,000 ± 
1-5,000 ± 
1-5,000 ± 
1-5,000 ± 
1-5,000 -f- 
1-10.000 + 
1-5,000 ± 
1-1.000 ± 

Season 1918 
1-10.000 db 
1-1.000 ± 
1-1,000 ± 
1-10,000 ± 
1-5,000 ± 
1-5,000 ± 
1-5,000 db 
1-10,000 -H 
1-5,000 ± 
1-5,000 -f 
1-5,000 ± 
1-10,000 ± 
1-1,000 ± 
1-5,000 ± 
1-1,000 ± 
1-5,000 ± 
1-1,000 ± 
1-5,000 ± 
1-1,000 + 
1-5,000 ± 
1-5,000 + 
1-5.000 ± 
1-5.000 ± 
1-1,000 ± 
1-5,000 ± 
1-1,000 ± 
1-10,000 ± 
1-1,000 zfc 
1-5,000 ± 
1-5.000 ± 
1-5,000 ± 



1-100:4 
1-100:2 
1-100:2 
1-500:5 
1-100:2 
1-500:4 
1-100:3 
1-500:3 
1-500:6 
1-500:4 
1-100:4 
1-500:3 



1-500: 
1-100 
1-500 
1-500 
1-100 
1-500 
1-500 
1-500 
1-100 
1-100 
1-500 
1-500 
1-100 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500 
1-500: 
1-100 
1-500 
1-500 
1-500 



1-100 + 
1-100 + 

i-sdo'i' 

1-500 + 
1-500 + 



G. 

G. 

G. 

G. 

G. 

G. 
75% 
50% 

G. 

G. 

G. 
50% 



50% 

N. 

N. 

G. 

P. 
75% 

G. 

N. 
50% 

G. 

P. 

75% 

G. 

G. 
75% 

P. 

G. 
75% 

N. 
50% 
50% 

G. 
G. 

75% 

75% 

G. 

50% 
75% 



• Fair in result column means practically free from symptoms; 
good means entirely free. 

[209] 



TABLE I.— PRESEASONAL TESTS AND TREATMENT 

WITH RAGWEED POLLEN (Continued) 
G = Good. P = Fair. N = None. 





Arc 


Dura- 


Patient 


of 
Onset 


tion 


42 


24 


15 


43 


39 


45 


44 


3 


8 


45 


32 


8 


46 


20 


13 


47 


1 


38 


48 


1 


20 


49 


50 


3 


50 


8 


9 


61 


29 


31 


52 


37 


11 


63 


7 


24 


64 


30 


9 


55 


37 


4 


56 


16 


7 


57 


19 


12 


58 


26 


6 


69 


17 


19 


60 


2 


17 


61 


28 


16 


62 


27 


22 


63 


22 


30 


64 


10 


3 


65 


6 


10 


66 


45 


5 


67 


4 


10 


68 


32 


3 


69 


38 


7 


70 


22 


6 


71 


30 


4 


72 


27 


7 


73 


16 


45 


74 


8 


26 


75 


49 


20 


76 


39 


16 


77 


36 


37 


78 


17 


3 


79 


25 


10 


80 


34 


12 


81 


1 


3 


82 


36 


4 


83 


22 


18 


84 


16 


4 


85 


38 


6 



Tests 

Before 

Treatment 



Number 

Treatments 

with 

Final 

Dilution 



Tests 
at End 

of 
Treat- 
ment 



Result 

of 
Treat- 
ment • 



Season 1919 
1-10,000 ± 
1-10,000 db 
1-10,000 ± 
1-10,000 ± 
1-10,000 ± 
1-5,000 ± 
1-10.000 ± 
1-10,000 db 
1-10.000 zfc 
1-10.000 d= 
1-5,000 ± 
1-20.000 ± 
1-20.000 + 
1-10,000 ± 
1-10,000 ± 
1-5,000-1- 
1-1,000 ± 
1-5,000 ± 
1-5,000 ± 
1-5,000 + 
1-10,000 ± 
1-10,000 + 
1-500 ± 
1-500 + 
1-10,000 + 
1-10,000 ± 
1-1,000 ± 
1-20,000 + 
1-1.000 d= 
1-10.000 ± 
1-10,000 ± 
1-5,000 ± 
1-10,000 + 
1-5,000 it 
1-500 + 
1-10,000 db 
1-10,000 ± 
1-10,000 ± 
1-5,000 + 
1-5,000 + 
1-5,000 
1-5,000 + 
1-10,000 + 
1-10.000± 



1-100:5 


1-100 + 


1-500:3 


1-500 -t- 


1-100:2 


1-100 d= 


1-100:4 


1-100 + 


1-100 :f 


1-500 + 


1-500:4 




1-100:2 


1-500 + 


1-500:5 




1-100:2 


1-100 + 


1-100:3 


1-100 + 


1-500:5 


1-100 + 


1-100:3 


1-100 + 


1-100:1 


1-1,000 + 


1-100:4 


1-100 + 


1-500:4 




1-100:4 


1-100 + 


1-500:5 


1-100.0 


1-500:3 


1-500 + 


1-100:4 


1-500 + 


1-100:4 


1-500 + 


1-500:5 




1-500:5 




1-100:2 


1-100.0 


1-100:4 




1-100:3 


1-100 + 


1-100:2 


1-500 + 


1-500:4 




1-100:2 


1-1.000 + 


1-100:4 


1-100.0 


1-500:2 




1-100:4 


1-1.000 + 


1-500:4 




1-500:5 


1-500 + 


1-100.4 


1-100 + 


1-100:1 




1-100:3 


1-1,000± 


1-500:4 


1-500 ± 


1-500:4 




1-100:3 


1-100.0 


1-500:5 




1-100:2 


1-500 + 


1-500:5 


1-5.000 + 


1-100:1 


1-100.0 


1-100:1 


1-100 + 



G. 

™% 

P. 
50% 

G. 

G. 

G. 
75% 

G. 

N. 

N. 

P. 
50% 

G. 
50% 
75% 

75^ 

G. 

G. 

G. 

G. 

G. 

N. 

G. 

P. 

N. 

G. 
75% 

G. 

G. 

G. 

G. 
50% 

G. 

P. 

N. 
P. 
P. 



* Fair in result column means practically free from symptoms; 
good means entirely free. 

[210] 



TABLE I— PRESEASONAL TESTS AND TREATMENT 

WITH RAGWEED POLLEN (Continued) 
G = Good. F = Fair. N = None. 





Ape 


Dura- 


Patient 


of 
Onset 


tion 


86 


14 


7 


87 


20 


6 


88 


44 


8 


89 


18 


10 


90 


15 


2 


91 


28 


20 


92 


10 


20 


93 


8 


2 


94 


33 


12 


95 


35 


35 


96 


12 


5 


97 


9 


8 


98 


37 


3 


99 


9 


8 


100 




1 


101 


2 


12 


102 


29 


6 


103 


15 


30 


104 


30 


15 


105 


23 


1 


106 


29 


40 


107 




8 


108 


24 


1 


109 


39 


10 


110 


1 


9 


111 


12 


9 


112 


30 


5 


113 


8 


27 


114 


3 


2 


115 


30 


5 


116 


41 


2 


117 


2 


17 


118 


8 


23 


119 


Infant 


23 


120 


Infant 


21 


121 


24 


12 


122 


30 


8 


123 


12 


5 


124 


Infant 


33 


125 


10 


5 


126 


35 


7 


127 


2 


47 


128 


14 


10 


129 


17 


2 



Tests 

Before 

Treatment 



Number 

Treatments 

with 

Final 

Dilution 



Tests 
at End 

of 
Treat- 
ment 



Result 

of 
Treat- 
ment* 



Season 1920 
1-5.000 zfc 
1-10.000 + 
1-10.000 + 
1-20.000 ± 
1-5,000 ± 
1-10,000 ± 
1-5.000 ± 
1-500 + 
1-5.000 + 
1-20.000 + 
1-10.000 
1-10.000 ± 
1-10.000 dz 
1-10.000 ± 
1-5,000 + 
1-5.000 ± 
1-5.000 ± 
1-10.000 + 
1-10.000 ± 
1-1.000 ± 
1-5,000 zfc 
1-5.000 + 
1-5.000 ± 
1-5.000 ± 
1-5,000 zt 
1-10.000 zfc 
1-10.000 zfc 
1-5,000 ± 
1-5.000 zfc 
1-5,000 + 
1-5.000 zfc 
1-10.000 zfc 
1-lO.OOOzfc 
1-10,000 zfc 
1-5.000 zfc 
1-5.000 + 
1-5.000 + 
1-10,000 zfc 
1-20.000 zfc 
1-10.000 dz 
1-5,000 dfc 
1-5.000 + 
1-5.000 + 
1-5.000 + 



1-500:5 
1-500:5 
1-500:4 
1-500:5 
1-500:5 
1-100:2 
1-500:4 
1-100:4 
1-500:5 
1-500:5 
1-500:4 
1-500:4 
1-500:5 
1-100:2 
1-500:6 
1-500:5 
1-500:4 
1-500:3 
1-500:3 
1-500:6 
1-500:6 
1-100:3 
1-500:4 
1-500:5 
1-500:5 
1-500:5 
1-500:5 
1-500:5 
1-500:5 
1-500:5 
1-500:5 
1-100:3 
1-500:6 
1-500:4 
1-500:5 
1-500:5 
1-500:5 
1-500:5 
1-500:4 
1-500:3 
1-500:4 
1-500:5 
1-500:5 
1-500:4 



1-1.000 + 

1-100+ ■ 

1-500+ ■ 
1-500+ ■ 



P. 

50% 
50% 
50% 
75^ 
G. 

75^ 

F. 

75% 

75% 

75% 
75<% 
75% 
75^ 

50% 
50% 
75% 
50% 

50% 

50% 
50% 
75% 

F. 
50% 
75% 

P. 

F. 

5^4 

F. 

75% 
50% 

75% 
75^ 

F. 

50% 



• Fair in result column means practically free from symptoms; 
good means entirely free. 

[211] 



TABLE I.— PRESEASON AL TESTS AND TREATMENT 

WITH RAGWEED POLLEN (Continued) 
G = Good. F = Fair. N = None. 





Age 


Dura- 


Patient 


of 
Onset 


tion 


130 


33 


3 


131 


20 


10 


132 


29 


10 


133 


19 


15 


134 


16 


6 


135 


27 


12 


136 


49 


5 


137 


34 




138 


4 


6 


139 


26 


8 


140 


33 


2 


141 


15 


6 


142 


8 


2 


143 


5 


85 


144 


25 


6 


145 


32 


10 


146 


20 


6 


147 


10 


20 


148 


35 


5 


149 


22 


8 


150 


33 


4 


151 


16 


4 


152 


24 


2 


153 


9 


45 


154 


20 


2 


155 


24 


6 


156 


21 


20 


157 


30 


25 


158 


4 


3 


159 


10 


20 


160 


18 


4 


161 


17 


3 


162 


29 


5 


163 


36 


2 


164 


7 


5 


165 


19 


1 


166 




25 


167 


30 


5 


168 


5 


4 


169 


15 


3 


170 


27 


1 


171 


29 


8 


172 


10 


54 


173 


14 


10 



Tests 

Before 

Treatment 



Number 

Treatments 

with 

Final 

Dilution 



Tests 
at End 

of 
Treat- 
ment 



Result 

of 
Treat- 
ment* 



Season 1920 
1-5.000 ± 
1-1.000 ± 
1-1.000 ± 
1-5.000 -f 
1-5.000 ± 
1-10.000 ± 
1-20.000 =h 
1-20,000 ± 
1-5.000 ± 
l-r^,000± 
1-5,000 zh 
1-5,000 -h 
1-5.000 ± 
1-5.000 zb 
1-5.000 ± 
1-10.000 ± 
1-1,000 -f 
1-5.000-1- 
1-5,000-1- 
1-10.000 ± 
1-5.000 ± 
1-5.000 ± 
1-5,000 ± 
1-10.000 ± 
1-5,000 -f 
1-5.000 ± 
1-5.000 ± 
1-5,000 ± 
1-500 -f- 
1-10.000 ± 
1-5,000 ± 
1-10.000 ± 
1-10.000 db 
1-20.000 ± 
1-1.000 -f 
1-500 ± 
1-20.000 ± 
1-5.000 ± 
1-5.000 ± 
1-10,000 -f- 
1-1. 000 it 
1-10.000 -f- 
l-10.000-|- 
1-10,000-1- 



-Cont'd 
1-500:3 
1-500:5 
1-500:5 
1-500:5 
1-500:3 
1-500:5 
1-500:4 
1-500:3 
1-500:4 
1-500:4 
1-500:3 
1-500:5 
1-500:4 
1-500:5 
1-500:5 
1-500:5 
1-500:4 
1-500:4 
1-500:5 
1-500:4 
1-500:5 
1-500:3 
1-500:4 
1-500:5 
1-500:4 
1-500:5 
1-500:5 
1-500:5 
1-500:6 
1-500:4 
1-100:1 
1-500:4 
1-500:4 
1-500:5 
1-500:5 
1-500:4 
1-500:5 
1-500:5 
1-100:1 
1-100:2 
1-500:3 
1-500:3 
1-100:1 
1-500:4 



1-100 



1-1.000 ± 



Pol. 



P. 

75% 
50% 
50/. 

?§1 
50% 
F. 
75% 
75% 
50% 
75% 

'?? 

F. 

F. 

75% 

F. 

509? 
75% 
50% 

G. 
75% 
60% 
75% 

F. 
50% 
50% 

75% 
759? 

P. 

75% 
75% 
50% 

75% 
50% 
50% 
O. 
75% 



• Fair in result column means practically free from symptom«; 
good means entirely free. 

[212] 



TABLE I.— PRESEASONAL TESTS AND TREATMENT 
WITPI RAGWEED POLLEN (Continued) 

G = Good. F = Fair. N = None. 





Age 


Dura- 


Patient 


of 
Onset 


tion 


174 


26 


2 


175 


19 


2 


176 


18 


7 


177 


8 


5 


178 


33 


2 


179 


29 


5 


180 


8 


20 


ISl 


3 


9 


182 


26 


10 


183 


30 


7 


184 


10 


8 


185 


28 


10 


186 


35 


15 


187 


11 


28 


188 


1 


28 


189 


16 


6 


190 


20 


10 


191 


6 


13 


192 


30 


10 


193 


13 


4 


194 


25 


5 


195 


4 


5 


196 




5 


197 


8 


14 


198 


27 


20 


199 


15 


25 


200 


28 


20 



Tests 

Before 

Treatment 



Number 

Treatments 

with 

Final 

Dilution 



Tests 
at End 

of 
Treat- 
ment 



Result 

of 
Treat- 
ment* 



Season 1920 
1-10.000 ± 
1-5.000 ± 
1-5,000 d= 
1-10,000 ± 
1-1.000 ± 
1-5.000 -t- 
l-1.000-f- 
1-10.000 ± 
1-5.000 ± 
1-10,000 ± 
1-40,000 ± 
1-10,000 ± 
1-10,000 ± 
1-10,000 ± 
1-5.000 -H 
1-20,000 ± 
1-1,000 it 
1-10.000 ± 
1-5.000 =h 
1-5.000 it 
1-5.000 4- 
1-5,000 ± 
1-5,000 ± 
1-10,000 ± 
1-10,000 + 
1-10,000 ± 
1-5.000 ± 



-Cont'd 
1-100:2 
1-500:5 
1-500:5 
1-500:4 
1-100:2 
1-100:3 
1-100:3 
1-500:3 
1-100:1 
1-100:2 
1-500:4 
1-500:5 
1-500:5 
1-500:4 
1-100:4 
1-500:4 
1-100:2 
1-500:5 
1-500:5 
1-500:5 
1-500:6 
1-100:3 
1-500:5 
1-500:6 
1-500:6 
1-500:6 
1-500:5 



1-1.000 db 
1-5.000 ± 

1-100+ ' 

i-500± ' 
1-500 ± 
1-1.000 + 

i-500± ■ 

1-100+ * 



•Fair in result column means practically free from symptoms; 
good means entirely free. 

but no higher. Therefore, in comparison with 
ragweed, in only 3.25 per cent, of the cases in 
Table 1 could goldenrod pollen be assumed as a 
possible cause of hay-fever. From the investiga- 
tions of Scheppegreir and others we know that 
the pollens of goldenrod, sunflower, golden-glow, 

' Scheppegrell, W. : Hay-Fever and Hay-Fever Pol- 
lens, Arch. Int. Med. 19:959 (July), 1917. 

[213] 



HAY-FEVER 

daisy and aster are not carried by the wind, and 
that their pollens are heavy and shed very spar- 
ingly, so that for these reasons patients are not 
exposed to these pollens unless the flowers are 
kept in the house or unless sensitive patients 
smell of the flowers; naturally, the patient can 
refrain from such intimate contact and need not 
be treated for these. 

Since the construction of Table 1 may not be 
entirely clear, the case of the second patient will 
be discust in detail as an example of all of 
the remaining cases presented in this and similar 
tables. Patient 2 began to have hay-fever at the 
age of 8; he had it for seven years; previous 
to treatment his skin test with ragweed pollen 
was slightly positive with a 1 : 5,000 dilution, 
therefore, treatment was begun with 0.15 c.c. of 
1 : 10,000 dilution. The schedule of treatments 
was carried out until he was given two treat- 
ments with the 1 : 100 dilution ; at the end of 
treatment his skin test was positive with the 
1 : 100 dilution, but it should be assumed that the 
test was negative with weaker dilutions, namely, 
1 : 500, etc. ; the result was that the patient was 
free from hay-fever during the August and Sep- 
tember season in 1917. Other symbols that may 
need explanation are the following: In the re- 
sult column ''good" means entirely free from 
symptoms, ''fair" means practically free, that is, 
not entirely free from symptoms but much better 
than 75 per cent. ; " 75 per cent. ' ' and ' ' 50 per 
cent. ' ' mean that amount of freedom or benefit ; 
"none" mjeans no benefit or no relief; however, 

[214] 



FORMS OF TREATMENT 

some of these patients did claim to be 25 per 
cent, relieved, but I do not wish to tabulate so 
little benefit. 

The results of treatment from the symptomatic 
standpoint in the 202 patients presented in Table 
1 were as follows : 45 patients, or 22 + per 
cent., had no symptoms ; 36 patients, or 17 + 
per cent., were practically free from symptoms; 
61 patients, or 30 -|- per cent., were benefited at 
least 75 per cent. ; 47 patients, or 23 + per cent., 
were benefited only 50 per cent., and 13 patients, 
or 6.5 per cent., were not benefited at all. Cor- 
relation of symptomatic benefit with the amount 
of treatment brings out the following facts : Of 
the forty-five patients who were entirely free 
from symptoms, twenty-three were given one or 
more treatments with the 1 : 100 dilution and 
twenty others were given four or more treatments 
with the 1:500 dilution. Of the thirty-six pa- 
tients who were practically free from symptoms, 
one-fourth received the 1 : 100 dilution from one 
to three times, practically one-half of the series 
were given the 1 : 500 dilution five or six timies, 
and nearly one-fourth were treated four times 
with this dilution. Of the sixty-one patients 
who were 75 per cent, improved, practically one- 
fifth were treated from one to five times with 
the 1 : 100 dilution, nearly one-half were treated 
fi.ve or six times with the 1 : 500 dilution, a few 
more than one-third were treated four times with 
the 1 : 500 dilution. Of the forty-seven patients 
who were 50 per cent, relieved, only seven, or 
approximately one-seventh, were treated with 

[215] 



HAY-FEVER 

the 1:100 dilution, approximately three-eighths 
were given the 1 : 500 dilution five or six times, 
about one-fifth were given four treatments with 
the 1 : 500 dilution, and nearly one-fourth were 
given only three treatments with the 1 : 500 dilu- 
tion. The thirteen patients who were not benefited 
will be discust in detail later. Therefore, 
it is very evident that one or more treatments 
with the 1 : 100 dilution yielded the best re- 
sults, and that five or more treatments with 
the 1 : 100 dilution yielded the best results, 
and that five treatments with the 1 : 500 dilution 
gave considerable better results than four ti'eat- 
ments with this dilution, altho four treat- 
ments with the 1 : 500 dilution are well worth 
giving; as the number of patients who were 
treated three times with the 1 :500 dilution in- 
creased, the amount of benefit gradually de- 
creased, until nearly one-quarter of the 50 per 
cent, benefited fell into this group; in other 
words, only three treatments with the 1 : 500 di- 
lution give poor results in comparison to giving 
four or better still five treatments with this 
dilution. When one stops to consider that the 
fifth or sixth treatment with the 1 : 500 dilution 
is equivalent in amount of protein to " at least 
one treatment with the 1 : 100 dilution, it is 
very evident that five or six treatments with 
the 1 : 500 dilution, or one treatment with the 
1 : 100 dilution, is the ideal treatment. 

Although little information is obtained by 
analyzing the table in regard to why some pa- 
tients were more benefited than others, and why 

[216] 



FOEMS OF TEEATMENT 

some were not benefited at all, after all it 
does seem worth doing. 

Concerning the thirteen patients who were 
not improved, none gave positive skin tests with 
the pollens of daisy, goldenrod, golden-glow or 
sunflower. The treatment of Patient 144 was 
given at irregular intervals; Patient 134 lost 
three weeks during treatment so that he could be 
given only three doses of the 1 : 500 dilution ; 
Patient 108 was given only four doses of the 
1 :500 dilution ; even tho many other pa- 
tients were greatly benefited by similar treat- 
ment, it may be fair to assume that the negative 
result with these three particular cases was 
due to insufficient treatment. Patient 83 gave 
as positive a skin test at the end of treatment 
as he did before treatment, and the last treat- 
ment produced an anaphylactic shock manifested 
by urticaria. Patients 72, 69 and 54 gave positive 
skin tests with a 1 : 1,000 dilution at the end of 
treatment, in spite of the fact that they all had 
received the 1 : 100 dilution one or more times. It 
may be safely stated that in the case of these four 
patients treatment did not desensitize the skin, 
and it is likewise probably true that, for some 
unknown reason, the patient's mucous mem- 
branes were not desensitized or that there was 
lack of union between the patients' antibodies 
and the treatment antigen. Patient 55 received 
four doses of the 1 : 100 dilution and at the end 
of treatment no dilution stronger than the 1 : 100 
gave a positive reaction, and Patient 14 was 
treated with the 1 : 100 dilution two times, so that 

[217] 



HAY-FEVER 

these two patients ought to have had sufficient 
pollen treatment. Patients 33, 24, 21, and 15 
all received the 1 : 500 dilution five times so that 
they also did not fall short of the average amount 
of treatment. The varying ages of onset and 
years of duration of symptoms, and the approxi- 
mately equal distribution between the two sexes 
and between the three different years, furnish 
no clues toward the cause of failure from treat- 
ment. It would seem that we must blame the 
individuality or idiosyncrasy of these particular 
patients for the time being, and, therefore, it 
should be admitted that with our present knowl- 
edge there are a few hay-fever victims who are 
not benefited by preseasonal pollen therapy. 

Of the forty-seven patients who were only 50 
per cent, improved, three showed evidence of 
lack of desensitization, as was noted in the previ- 
ous paragraph, in that one case following four 
treatments with the 1 : 500 dilution and another 
following six similar treatments gave positive 
skin tests with a 1 : 1,000 dilution of the pollen 
protein ; the third gave a positive skin test with 
the 1 : 5,000 dilution following two doses of 
1 : 100, and it is interesting that this patient was 
not shocked. It is difficult to explain why 
fifteen patients who were treated five times with 
the 1 : 500 dilution, and three patients who were 
similarly treated six times should not receive 
more than 50 per cent, relief when so many 
more experienced greater benefit from the same 
treatment. It is still more difficult to understand 
why the six patients who were treated from 
[218] 



FOEMS OF TEEATMENT 

one to four times with the 1 : 100 dilution of 
pollen protein should be only 50 per cent, im- 
proved, especially since at the end of treatment 
one patient gave negative tests with the whole 
pollen protein and two others gave positive reac- 
tions with no stronger than the 1 : 100 dilution. 
Attention should be called to the decreased 
sensitivity of the patient as evidenced by the 
skin test following a satisfactory series of treat- 
ments. Fifty-one patients were tested at the 
end of treatment. One-third of these gave a 
more or less positive skin test with the 1 : 100 
dilution but did not react to a more dilute so- 
lution of the pollen protein; the same number 
gave a more or less positive skin test with the 
1 : 500 dilution, but failed to react to a more di- 
lute pollen protein solution; one-half of these 
were given treatments with the 1 : 100 dilution, 
and the other half with the 1 : 500 dilution ; a 
few were given only three doses of the 1 : 500 
dilution ; five failed to react at all with the 1 : 100 
dilution, four were treated with the 1 : 100 di- 
lution; one patient who was treated with the 
1 : 100 dilution failed to react to the whole pollen ; 
eight gave a more or less positive skin test with 
the 1 : 1,000 dilution, four having been treated 
with the 1 : 100 dilution without producing ill 
symptoms; two patients reacted with the 1 : 5,000 
dilution of pollen protein — one. Patient 83, was 
shocked (urticaria) following the fifth treatment 
with a 1 : 500 dilution and was unimproved, 
whereas the other. Patient 178, had received 
two doses of the 1 : 100 dilution but was not 

[219] 



HAY-FEVER 

shocked and was 50 per cent, improved. There- 
tore, in all but two cases, treatment decreased the 
sensitivity of the patient, as evidenced by the 
skin test; or to be more specific, in practically 
three-fifths of the cases the intensity of the 
skin test diminished 100 times and in practically 
the remaining two-fifths it was decreased at 
least twenty times; the larger the number of 
treatments given, the greater was the decrease in 
the intensity of the skin test. 

Pollens, other than ragweed, that might com- 
plicate the cause and treatment of hay-fever at 
this season of the year in New England have 
already been mentioned, and to a certain extent 
these have been eliminated. Since, however, a 
few patients listed in Table 1 did react rather 
strongly to other pollens, it may be advisable 
to mention them. Patients 4, 6, 23 and 29 gave 
more or less positive skin tests with a 1 : 1,000 
dilution of daisy but the first two were free from 
symptoms and the other two were 75 per cent, 
benefited by six and four treatments, respec- 
tively, of a 1 : 500 dilution of " rag^veed pollen 
alone. Patient 26 reacted to a 1 : 1,000 dilution 
of corn pollen but was 75 per cent, improved by 
three doses of 1 : 500 dilution of ragweed pollen. 
Patients 19, 28 and 74 reacted more or less to a 
1 : 1,000 dilution of goldenrod pollen, but fol- 
lowing five treatments with 1 : 500 ragweed pol- 
len. Patients 19 and 28 were free from symp- 
tom^s, and Patient 74 was 75 per cent, benefited. 
Therefore, for reasons already stated, it would 
seem that pollens other than ragweed played no 

[220] 



FOEMS OF TREATMENT 

part in the cause of haj^-fever at this particular 
season. 

The age at which hay-fever began, and the 
/lumber of years that the patient has had hay- 
fever, seem to play no part in the cause or the 
treatment of this type of hay-fever. Neither does 
the sex of the patient have any bearing even on 
the frequency of the condition. The patients 
in Table 1 were equally divided between the two 
sexes. A number of the patients were treated at 
five-day intervals rather than, as was usually the 
case, at seven-day intervals. Altho statistics 
would not reveal any information on this point, 
it is my impression that the seven-day interval 
is preferable to the five-day interval. The in- 
dividuality of the patient certainly plays a great 
part in the treatment and in the results of treat- 
ment of hay-fever; however, any definite infor- 
mation in regard to this point can not be ob- 
tained. 

The same season in different years varies 
greatly in regard to the abundance of pollen, the 
beginning and the end of pollination and the 
frequency of colds that may be mistaken for 
hay-fever and thereby complicating the results 
of treatment. For example, in 1918, ragweed be- 
gan to pollinate about August 8 ; 1918 and 1919, 
frosts sufficiently heavy to stop pollination oc- 
cured about the middle of September, and even 
during all of September the weather was cold 
and rainy, so that not only was pollination below 
normal but head colds were frequent and the 
influenza epidemic was present. The season of 

[221] 



HAY-FEVER 

1920 was very favorable for ragweed ; no frosts 
severe enough to injure it occurred, and pol- 
lination continued from about August 13 un- 
til October 1, at which time the plant naturally 
completed pollination and went to seed. There 
was no epidemic of colds and very little rain. 
For these reasons the results of preseasonal or 
preventive treatment with ragweed pollen in 
1920 are of great value and are a true test for 
the treatment. Before considering these re- 
sults, however, it should be noted that the 
amount of treatment given in this particular 
year was, in general, less than that given in 
preceding years. On referring to Table 1, sea- 
son of 1920, the following are seen to have been 
the results of ragweed treatment; of the 115 
patients treated, 27 per cent, experienced little 
or no hay-fever; 40 per cent, were 75 per cent, 
relieved; about 66 per cent, were, therefore, 
either 75 per cent, relieved or more so, and less 
than 33 per cent, had as little as 50 per cent, 
relief, whereas only three patients or 2.6 per 
cent., were not benefited by treatment. 

Before Table 2 is discust, attention should 
be called to the plants that pollinate during 
June and July, the early hay-fever or so-called 
rose cold season. In the New England States 
some of the compositae, the most important of 
which is daisy, pollinate at this time, but for 
reasons already given daisy pollen rarely, if 
ever, is a cause of hay-fever. Such plants as the 
lilies, sorrel, buttercup and others pollinate 
at this time, but when tested no patient has been 

[222] 



FORMS OF TREATMENT 

found to be sensitive to these, and if they ever 
cause hay-fever it is because of immediate nasal 
contact with the blossom. The rose which pol- 
linates at this time is rarely a cause of hay-fever 
since it is not a wind pollinated plant. Since, 
however, rose is commonly suspected to be the 
cause of hay-fever or rose colds, and .^ince the 
pollen of rose is occasionally the actual cause, 
skin tests with rose pollen frequently have to 
be done, if for no other reason than to satisfy 
the patient. Altho in Table 2 only two 
patients (219 and 226) are represented as hav- 
ing been tested with rose pollen, thirty-three 
others of the fifty-two were tested with rose, and 
thirty-one failed to react more than doubtfully 
with the whole pollen of either the red or the 
white rose, and the two who did give a positive 
skin test with the whole pollen failed to react 
at all with a 1 : 100 dilution of the pollen. The 
thirty-five patients who were tested with rose 
pollen were tested with it because they thought 
roses caused their hay-fever, and the other pa- 
tients in Table 2 were not tested with it because 
they were sure that roses did not cause their 
hay-fever. Therefore, it would seem that in 
New England roses were rarely the chief cause 
of hay-fever. 

The cause of hay-fever during June and July 
in the New England States is practically limited 
to the pollens of the grass family. Lawn grass 
begins to pollinate early in May, as a rule, but 
since it is rare for hay-fever to begin early in 
May, lawn grass pollen is probably rarely, if 

[223] 



HAY-FEVER 

ever, the chief cause of hay-fever. Since, how- 
ever, lawn grass continues to pollinate through- 
out the summer even when it is repeatedly mowed 
closely, with those patients who are sensitive to 
the pollens of other grasses and are either not 
treated or are insufficiently treated with the 
particular grass pollen that is the chief cause 
of hay-fever, exposure to lawn grass pollen may 
be a complicating cause or may aggravate the 
symptoms of hay-fever. Orchard grass polli- 
nates during July, but this type of grass grows 
in more or less secluded places, and it is not 
commonly encountered. The same thirty-five 
patients who were tested with rose pollen were 
also tested with orchard grass pollen. Thirty 
of them failed to give positive skin tests with 
the whole pollen, and the five who gave a posi- 
tive test with the whole pollen, failed to react 
with a 1 : 100 dilution of the pollen extract ; 
therefore, orchard grass rarely, if ever, is an 
actual cause of hay-fever. Since com is a mem- 
ber of the grass family, and since the table 
variety pollinates during July, it must be con- 
sidered among the possible causes of early hay- 
fever. Forty of the fifty-two patients presented 
in Table 2 were tested with sweet corn pollen; 
twenty-two failed to react at all, and eighteen 
gave a positive skin test with the whole pollen, 
altho no tests with a 1 : 100 dilution of the 
pollen extract were positive. The large number 
of positive tests with the whole pollen was prob- 
ably due, in part, at least, to the very large 
amount of protein present in corn pollen in 

[224] 



TABLE 2.— PRESEASONAL TESTS AND TREATMENTS 

WITH GRASS POLLENS 
G = Good. F = Fair. N = None. 









Tests Before Treatment 




Age of 


Dura- 








Patient 


Onset 


tion 














Timothy 


Red Top 


June Grass 










Season 1917 




201 


50 


10 


1-1.000 ± 


1-1,000 ± 




202 


14 


8 


1-10 000 it 


1-1 000 ± 





203 


23 


18 


1-500 ± 


1-1,000 ± 




204 


12 


40 


1-5 000 4- 


1-1 000 ± 




205 


30 


5 


1-1.000 -f- 


1-1, 000 =b 




206 


10 


9 


1-5 000 ± 


1-100 + 




207 


27 


10 


1-1.000 ± 


1-500 ± 




208 


6 


5 


1-1.000 -f- 


1-100 ± 




209 


7 


14 


1-5.000 ± 


1-5.000 ± 
Season 1918 




210 


25 


7 


1-10.000 ± 


1-5.000 ± 





211 


34 


10 


1-1 000 ± 


1-5 000 ± 




212 


27 


18 


1-1.000 db 


1-1.000 =fc 




213 


19 


4 


1-5 000 4- 


1-1 000 + 




214 


32 


13 


1-500 d= 


1-500 ± 




215 


13 


6 


1-5.000 ± 


1-500 ± 




216 


5 


11 


1-1.000 + 


1-100.0 












Season 1919 




217 


20 


15 


1-5.000 db 


1-1,000 ± 


1-1,000 ± 


218 


33 


12 


1-1.000 -f- 


1-1.000 + 


1-1.000 + 


220 


7 


2 


1-5.000 ± 


1-1.000 ± 


1-5.000 ± 


221 


20 


8 


1-1.000 + 


1-1.000 + 


1-1.000 + 


222 






1-5.000 ± 


1-1 .000 ± 


1-1.000 db 


223 


1 


37 


1-5.000 ± 


1-5.000 dc 


1-5,000 d= 


224 


8 


3 


1-1 .000 ± 


1-1.000 ± 


1-1.000 ± 


225 


12 


5 


1-1.000 ± 


1-500 + 
Season 1920 


1-1.000 ± 


227 


9 


2 


1-5.000 ± 


1-5.000 ± 


1-5.000 ± 


228 


3 


11 


1-1.000 ± 


1-1.000 + 


1-1,000 + 


229 


23 


4 


1-5.000 ± 


1-5.000 + 


1-1.000 + 


230 


23 


6 


1-5.000 ± 


1-5.000 ± 


1-500 + 


231 


8 


5 


1-10.000 + 


1-10.000 + 


1-5.000 + 


232 


29 


15 


1-1.000 + 


1-1.000 ± 


1-500 dz 


233 


11 


3 


1-10.000 + 


1-10.000 + 


1-10,000 + 


234 


23 


25 


1-1,000 ± 


1-1.000 ± 


1-5.000 ± 


235 


21 


30 


1-10.000 ± 


1-1.000 + 


1-5.000 dz 


236 


36 


11 


1-5.000 + 


1-1.000 + 


1-5.000 + 


237 


13 


4 


1-1,000 + 


1-1.000 + 


1-1.000 + 


238 


12 


4 


1-5,000 ± 


1-5.000 ± 


1-5.000 + 


239 


20 


2 


1-500 + 


1-5.000 ± 


1-1,000 + 


240 


22 


8 


1-5.000 ± 


1-5.000 + 


1-5.000 -- 


241 


15 


12 


1-1.000 + 


1-5,000 ± 


1-5.000 zb 


242 


7 


5 


1-500 + 


1-500 ± 


1-100 ± 


242 


6 


40 


1-5.000 + 


1-5.000 ± 


1-5.000 zfc 


244 


30 


22 


1-5.000 + 


1-5.000 + 


1-5.000 + 


245 


19 


1 


1-1.000 ± 


1-500 ± 


1-1,000 ± 



[225] 



TABLE 2.— PRESEASONAL TESTS AND TREATMENTS 
WITH GRASS POLLENS (Continued) 











Tests Before 
Treatment 




Patient 


Age of 


Dura- 










Onset 


tion 














Timothy 


Red Top 


June Grass 


246 


1 


20 


Negative 


1-1,000± 


Negative 


247 


4 


4 


1-5.000 + 


1-1.000± 


1-5.000 + 


248 




4 


1-5.000-1- 


1-500 ± 


1-1.000 + 


249 


21 


20 


1-5,000 ± 


1-1.000 -t- 


1-5.000 + 


250 


16 


19 


1-5.000 -f- 


1-1.000 + 


1-5,000 + 


251 






1-500 ± 


1-100.0 


1-500 ± 


252 


14 


9 


1-500 ± 


1-500 ± 


1-500 ± 


219 




3 


1-1,000 ± 


1-1,000 ± 


1-1,000 ± 
Rose 1-500 + 


226 


26 


38 


Negative 


Negative 


Rose 1-500 + 



comparison to the small amount of protein pres- 
ent in other pollens. Corn pollen is very heavy, 
it rapidly descends to the ground and is carried 
by air currents or wind only a few feet, there- 
fore, intimate exposure would be required to 
produce symptoms; furthermore, only rarely 
would a person be unable to avoid it. Therefore, 
corn pollen must rarely, if ever, be considered a 
cause of hay-fever in the New England States 
where no large acreage exists in any locality as 
is the case in the West. This same statement is, 
likewise, true of wheat, oats, barley and rye. 

The grasses, then, with which we are concerned 
in New England are June grass, Timothy and 
redtop, the pollens of which are light and are 
carried by wind considerable distances. June 
grass begins to pollinate some years as early as 
the middle of May; when the season is 
very late, it does not pollinate before the last 
day or two in May; pollination continues for 
about three weeks. Timothy and redtop begin 
£226] 



TABLE 2— PRESEASONAL TESTS AND TREATMENTS 

WITH GRASS POLLENS (Continued) 
G = Good. F = Fair. N = None. 



Patient 


Age of 
Onset 


Dura- 
tion 


Number of Treatments with 
Final Dilution 




Timothy 


Red Top 


June Grass 


201 


50 
14 
23 
12 
30 
10 
27 
6 
7 

25 
34 
27 
19 
32 
13 
5 

20 

33 

7 

20 

i 

8 
12 

9 

3 

23 

23 

8 

29 

11 

23 

21 

36 

13 

12 

20 

22 

15 

7 

6 

30 


10 
8 

18 

40 
5 
9 

10 
5 

14 

7 
10 
18 

4 
13 

6 
11 

15 

12 

2 

8 

37 
3 
5 

2 

11 

4 

6 

5 

15 

3 

25 

30 

11 

4 

4 

2 

8 

12 

5 

40 

22 


1-100:2 
1-500:3 


Season 1917 




202 






203 


1-100:3 




204 


1-500:3 
1-100:1 
1-500:3 
1-100:3 
1-100:3 
1-100:3 

1-100:1 
1-100:1 
1-100:2 
1-100:1 
1-100:2 
1-100:3 
1-100:4 

1-100:2 
1-100:3 
1-100:3 
1-500:3 
1-500:4 
1-500:5 




205 






206 






207 






208 






209 






210 


Season 1918 




211 


i-iod:i 

1-100:2 




212 




213 




214 






215 






216 






217 


Season 1919 




218 






220 






221 






222 






223 






224 


1-500:4 




225 


1-500:4 

1-500:4 
1-500:3 
1-500:6 
1-500:4 
1-500:4 
1-500:5 
1-500:3 
1-500:3 
1-500:4 
1-500:3 
1-500:4 
1-500:4 
1 500:4 
1-100:1 
1-100:1 
1-500:4 
1-500:2 
1-500:4 




227 


Season 1920 




228 




1-500:3 


229 




1-500*4 


230 




1-500:2 


231 




1-500 '4 


232 






233 






1-1 000-3 


234 




1-500:2 


235 




1-500:1 


236 




1-1,000:2 


237 






238 




1 500-2 


239 




1-500:4 


240 




1-500:4 


241 




1-500:2 


242 




1-500:4 


243 






244 




1-500:4 



[227] 



TABLE 2.— PRESEASONAL TESTS AND TREATMENTS 
WITH GRASS POLLENS (Continued) 



Patient 


Age of 
Onset 


Dura- 
tion 


Number of Treatments with 
Final Dilution 




Timothy 


Red Top 


June Grass 


245 


19 

2i 
16 

14 

26 


1 

20 

4 

4 

20 

19 

9 
3 

38 


1-500:5 




1-500:5 


246 


1-100:4 




247 


1-500:5 
1-500:5 
1-500:4 
1-500:5 
1-500:5 
1-100:5 


1-1,000:2 


248 






249 






250 






251 




1-500:5 


252 






219 


1-500:5 

Negative 


Rose 1-500-5 


226 




Rose 1-500:3 









to pollinate between the middle of June and the 
first of July, depending on the season, and pol- 
lination continues until the middle or last of 
July; usually, the season of pollination lasts 
about six weeks. Therefore, in order to com- 
plete the schedule of treatments mentioned 
earlier in this paper as being desirable, presea- 
sonal treatment with June grass must begin the 
first of March at the latest, and with timothy and 
redtop it must begin the middle of March. 

Analysis of Table 2 shows the results of pre- 
seasonal treatment for the early type of hay- 
fever. Of the fifty-two patients treated, twenty- 
one, or 40.4 per cent., were free from symptoms ; 
nine, or 17.3 per cent., were practically free 
from symptoms; ten, or 19.2 per cent., were 75 
per cent, relieved; nine, or 17.3 per cent., were 
50 per cent, relieved, and three, or 5.8 per cent., 
were not benefited. Twenty-eight of the pa- 
tients were treated with timothy grass pollen 
alone, three with redtop alone, one with rose 
[228] 



TABLE 2.— PRESEASONAL TESTS AND TREATMENTS 
WITH GRASS POLLENS (Continued) 

G = Good. F = Fair. N = None. 



Patient 


Age of 
Onset 


Dura- 
tion 


Tests at End of 
Treatment 


Result 
of 




Timothy 


Red Top 


June Grass 


Treat- 
ment 


201 


50 
14 
23 
12 
30 
10 
27 
6 
7 

25 
34 
27 
19 
32 
13 
5 

20 

33 

7 

20 

i 

8 
12 

9 

3 

23 

23 

8 

29 

11 

23 

21 

36 

13 

12 

20 

22 

15 

7 

6 

30 


10 

8 
18 
40 

5 

9 
10 

5 
14 

7 
10 
18 

4 
13 

6 
11 

15 

12 

2 

8 

37 
3 
5 

2 

11 

4 

6 

5 

15 

3 

25 

30 

11 

4 

4 

2 

8 

12 

5 

40 

22 


....... 

i-ioo.o 

1:100.0 
1-100 ± 

1-100 ± 
1-100 ± 
1-100 ± 

i-5o6± 






Season 1917 




G. 


202 






G. 


203 






50% 


204 






205 






75% 
G. 


206 






207 






G. 


208 






G. 


209 






G. 


210 


Season 1918 




G. 


211 






G. 


212 






G. 


213 






G. 


214 






G. 


215 






F. 


216 




1-1.000 ± 
l-500± 
1-500 -H 


G. 


217 

218 
•220 
221 


Season 1919 
1-1, 000 i 
1-500 ± 
1-500 + 


G. 
G. 
G. 

5^% 


222 






223 
224 


1-500 ± 


1-500 ± 


G. 

60% 


225 






227 


Season 1920 




75^ 
75% 
50% 
75% 
60% 
50% 


228 






229 






230 




231 




232 






233 






75% 

60% 

p. 


234 




235 






236 






«0% 


237 




238 






«0% 


239 






240 






T' 


241 






242 




p. 


243 






75% 


244 















[229] 



TABLE 2— PRESEASONAL TESTS AND TREATMENTS 
WITH GRASS POLLENS (Continued) 



Patient 


Age of 
Onset 


Dura- 
tion 


Tests at End of 

Treatment 


Result 

of 
Treat- 




Timothy 


Red Top 


June Grass 


ment 


245 


19 
26 


1 

20 

4 

4 

20 

19 

9 

3 

38 








75% 


246 






247 






F. 


248 






N. 


249 






75% 

75^ 

F. 


250 




251 






252 






G. 


219 






P. 


226 






G. 











alone, two with timothy and redtop together, 
one with redtop and rose together and seven- 
teen with timothy and June grass pollens to- 
gether. Altho these facts are of interest, 
much valuable information is missed unless par- 
ticular attention is given to each year ; therefore, 
each year will be discust separately. 

During the season 1917, nine patients were 
treated. Only one patient (203) was treated 
with redtop pollen, because this patient was 
more sensitive to dilutions of redtop pollen ex- 
tract than to timothy pollen extract; the re- 
maining eight patients were treated with timothy 
pollen extract alone because all but two were 
more sensitive to timothy pollen extract than to 
redtop pollen extract, and since these two were 
equally sensitive to both pollen extracts, timothy 
was selected for treatment because it was thought 
that timothy was more prevalent than redtop. 
Judging from the excellent results and the de- 
creased sensitivity of the patients, there is every 
[230] 



FOEMS OF TEEATMENT 

reason to believe that all patients had a suffi- 
cient number of treatments, that all but two, 
who were 50 and 75 per cent., respectively, re- 
lieved by treatment with redtop pollen extract, 
were treated by the proper pollen. As a matter 
of fact, the two patients who were only 50 per 
cent, and 75 per cent, relieved had most of their 
symptoms during June rather than in July 
which fact would make one suspicious that some 
pollen other than those tested was the cause of 
symptoms; tests were made with orchard grass, 
corn and rose, none of which reacted in a di- 
lution of 1 : 100, but June grass, which also polli- 
nates during June, was not tested. With the 
exception of these two cases, timothy pollen ex- 
tract would seem to have protected against red- 
top exposure since five of the patients were very 
sensitive to redtop pollen extract. 

During 1918, seven patients were treated, and 
all but one were free from symptoms and that 
one was practically free. All patients were 
treated one or more times with the 1 : 100 dilu- 
tion and all but two were treated with timothy 
pollen extract alone ; these two were treated with 
the extracts of timothy and redtop pollens to- 
gether. Therefore, the same conclusions that were 
drawn from the 1917 series hold true for the 1918 
series, namely, that all patients had a sufficient 
number of treatments, that treatment with timo- 
thy pollen extract protects against redtop expo- 
sure, that, as a rule, patients are more sensitive 
to timothy pollen than to any other pollen preva- 
lent at that time, with the possible exception of 

[231] 



HAY-FEVER 

June ^ass which was not tested, and that the 
reason why two patients were treated with red- 
top pollen in addition to timothy pollen was 
because one was more sensitive to redtop than 
to timothy and the other was equally sensitive 
to both. 

During 1919, eight patients were treated with 
the result that five were free from symptoms, 
one other was practically free, and two were 
only 50 per cent, relieved. Of the two patients 
(221 and 224) who were only 50 per cent, bene- 
fited, one had only three treatments with timothy 
pollen extract 1 : 500 and the other was treated 
with redtop instead of timothy; both patients 
had more symptoms in June than in July. There- 
fore, as regards timothy and redtop the same 
conclusions that were true of 1917 and 1918 
were equally true for 1919. In 1919, tests were 
made with June grass and on referring to the 
table, season 1919, it will be seen that the eight 
patients reacted as strongly to June grass pollen 
as to redtop; some reacted more strongly to 
it, and all but two were as sensitive to June 
grass as to timothy pollen extract. It is also 
noted that four patients, who were tested with 
the three grass pollens at the end of timothy 
pollen treatment, showed a much greater de- 
crease in sensitiveness to timothy pollen than to 
redtop or to June grass pollen. Therefore, since 
there is evidence that timothy pollen treatment 
seems to protect against redtop pollen exposure, 
as has already been shown, and since the pa- 
tients in 1917 and 1919 who were least benefited 

[232] 



FORMS OF TREATMENT 

by treatment, either by timothy or redtop, had 
most of their symptoms during the usual time of 
June grass pollination rather than during the 
time that timothy and redtop pollinate, and 
since in 1919 it was shown that early hay-fever 
patients are very sensitive to June grass pollen 
extract, it was deemed best to treat suitable pa- 
tients with June grass pollen during 1920. 

During the 1920 season, only three of twenty- 
eight patients were to any extent less sensitive 
to June grass pollen extract than to timothy 
pollen extract, and three of the patients were 
more sensitive to June grass pollen than to 
timothy. Therefore, in seventeen patients treat- 
ment was given with June grass pollen extract 
together with timothy pollen extract. The re- 
sults of this mixed treatment were: One pa- 
tient was free from symptoms, five were practi- 
cally free, five were 75 per cent, relieved, five 
w^ere 50 per cent, relieved, and one was not 
benefited; a very poor showing as compared to 
treatment with timothy pollen extract alone dur- 
ing the three previous years. It is also noted 
that only two patients who were treated with the 
mixture were given as many as one treatment 
with timothy, 1 : 100, which is desirable and 
which was the case in previous seasons when ex- 
cellent results were obtained; treatment with 
a mixture of the two pollens did not and will 
not permit of sufficient treatment with either 
one, and in this instance it is evident that a 
part, at least, of the poor results, if the three 
former seasons are a guide, was due to insuffi- 

[233] 



HAY-FEVER 

cient treatment with timothy pollen. The ab- 
sence of treatment with redtop pollen can not 
explain the poor results, since in the three former 
seasons excellent results were obtained in the 
absence of redtop treatment. 

Special attention is called to Patients 246, 219 
and 226 because their cases are of considerable 
interest. Patient 246 was sensitive to redtop 
pollen alone and was practically free from symp- 
toms following four treatments with the 1 : 100 
dilution of redtop pollen extract. Not only was 
this patient free from symptoms while in New 
England, but he was also free while in 
Wyoming and was practically free while in 
California. Patient 219, who was practically 
equally sensitive to the pollens of the three 
grasses and to rose, was practically free from 
symptoms following treatment with equal parts 
of redtop and rose pollen extracts. Patient 226, 
who was sensitive to rose pollen only, was free 
from symptoms following treatment with rose 
pollen extract. Therefore, only two rose cases 
were encountered in the four seasons during 
which fifty grass cases were tested and treated. 

My conclusions, based on a four years' ex- 
perience with the treatment of June and July 
hay-fever, are: While the pollen of timothy 
grass is the chief cause of hay-fever, and suffi- 
cient treatment with it alone gives excellent 
results, it is necessary to test all patients with 
the pollens of redtop, June grass and rose since 
an occasional patient is more sensitive to one 
of these pollens than to timothy pollen, and, 
[234] 



FORMS OF TREATMENT 

therefore, such a patient may need treatment 
with one of them rather than with timothy 
pollen. When the same patient, as is frequently 
the case, is equally sensitive to the dilutions 
of the pollen extracts of timothy, redtop and 
June grass, it is advisable to treat the patient 
with timothy pollen extract alone because there 
is sufficient evidence that treatment with timothy 
pollen will protect against redtop pollen exposure, 
provided one or more treatments are given with 
the 1 : 100 dilution of the pollen extract ; timothy 
and redtop pollinate at the same time, and red- 
top is less prevalent than timothy. Sufficient 
treatment with timothy pollen extract seems to 
protect also against June grass pollen exposure,- 
but since, as is often the case, June grass pol- 
lination is well advanced or even sometimes com- 
pleted before timothy pollination begins, the 
patients being treated with timothy have not had 
sufficient treatment with timothy pollen to pro- 
tect them completely against June grass pollen, 
consequently some of these patients will have 
more or less symptoms from June grass exposure, 
as happened in 1917 with Patients 203 and 205 ; 
in 1919, with Patients 221 and 224, and in 1920 
with Patients 232 and 249. In 1918, when 
June grass pollination was late, timothy treat- 
ment was successful, and the few cases in Table 
2 that were tested with the three grass pollens at 
the end of much timothy treatment alone, were 
considerably less sensitive to all of the grass 
pollens and all of the patients were free from 
symptoms. Unless treatment with June grass 

[235] 



TABLE 3.— INSUFFICIENT POLLEN TREATMENT 

N = None. F = Fair. 









Tests 


Number of 


Result 


Patient 


Age of 


Dura- 


Before 


Treatments 


of 




Onset 


tion 


Treatment 


with Final 
Dilution 


Treat- 
ment 


Ragweed 












253 


32 


13 


1-10.000 + 


1-1.000:2 


N. 


254 


22 


4 


1-5.000 ± 


1-1.000:3 


50% 


255 


3 


10 


l-5.000± 


1-1.000:3 


75% 


256 


18 


5 


1-1.000 ± 


1-1.000:3 


50% 


257 


14 


24 


1-5.000 ± 


1-1,000:2 


50% 


258 


16 


45 


1-5.000 ± 


1-1,000:2 


50% 


259 


19 


15 


1-5,000 ± 


1-1,000:2 


25% 
75% 


260 


28 


14 


1-1.000 + 


1-1,000:2 


261 


13 


9 


1-5,000 dz 


1-1,000:3 


50% 


262 


39 


10 


1-5.000 + 


1-1.000:3 


N. 


263 


31 


2 


1-1.000 ± 


1-500:2 


N. 


264 


3 


9 


1-10.000 + 


1-5.000:4 


N. 


265 


6 


12 


1-10,000 + 


1-1.000:2 


50% 


266 


16 


7 


1-10.000 d= 


1-1.000:3 


75% 


267 


44 


10 


1-10,000 ± 


1-5.000:5 


50% 


289 


16 


45 


1-10,000 ± 


1-500:2 


50% 
50% 
50% 


268 


27 


12 


1-10.000 ± 


1-500:2 


269 


44 


6 


1-5,000 + 


1-500:2 


271 


14 


9 


1-5.000 ± 


1-1.000:2 




272 


9 


2 


1-5.000 ± 


1-5,000:5 


50% 


273 


14 


10 


1-5.000 + 


1-500:2 


N. 


274 


29 


3 


1-10,000 ± 


1-5.000:1 


T" 


275 


3 


49 


1-10,000 db 


1-500:2 


276 


3 


6 


1-20.000 ± 


1-5.000:3 


50% 
50% 


277 


9 


9 


1-10.000 db 


1-500:2 


278 


3 


20 


1-10.000 ± 


1-5.000:4 


50% 


279 


16 


16 


1-10.000 ± 


1-500:1 




280 


5 


19 


1-10.000 ± 


1-1.000:2 


fA 


281 


18 


3 


1-10.000 ± 


1-500:2 


282 


35 


12 


1-10,000 ± 


1-1.000:2 


F. 


283 


31 


6 


1-10,000± 


1-500:2 


75% 


284 


35 


15 


1-10,000 it 


1-500:2 


285 


13 


16 


1-1.000 + 


1-500:2 


75% 


294 


11 


7 


1-5,000 ± 


1-500:2 


50% 


295 


31 


5 


1-5,000 db 


1-500:2 


N. 


296 


20 


17 


1-5.000 db 


1-500:1 


50% 


297 


22 


25 


1-5.000 ± 


1-500:2 


60% 


298 


11 


7 


1-5.000 ± 


1-500:2 


299 


37 


18 


1-5.000 ± 


1-500:2 


50% 


270 


41 


7 


1-5.000 ± 


1-500:2 


Timothy 












286 


30 


4 


1-5,000 db 


1-1.000:2 


N. 


287 


19 


10 


1-10,000 ± 


1-5.000:3 


N. 


288 


30 


5 


1-5,000 ± 


1-1,000:3 


T- 


290 


14 


6 


1-5,000 db 


1-1,000:2 


291 


8 


3 


1-1.000 ± 


1-500:2 


50% 


292 


14 


14 


1-10.000 rb 


1-500:2 


N. 


293 


22 


5 


1-10.000 ± 


1-5,000:5 


50% 



[236] 



FORMS OF TREATMENT 

pollen is begun earlier than is customary with 
timothy pollen, patients will not be treated suffi- 
ciently with June grass pollen. Therefore, treat- 
ment with both timothy pollen and June grass 
pollen extracts together will not only be insuffi- 
cient to protect against early June grass pollina- 
tion (Patients 229, 233, 234 and 238, all of whom 
had symptoms in late May and early June), but 
the combination of the two pollen extracts nec- 
essarily retards and diminishes the amount of 
treatment that might be given with timothy 
alone. Table 2 shows this to be the usual case. 
Therefore, I am opposed to preseasonal treat- 
ment with pollen mixtures, except on rare oc- 
casions, and in the case of June grass it is better 
to take a chance on a late season with timothy 
protection, or even an early season with few 
symptoms, than to treat with it in conjunction 
with timothy when timothy treatment is essential. 

In Table 3 are presented patients v/ho had in- 
sufficient pollen treatment, and by insufficient 
is meant that for some reason or other the com- 
plete schedule of treatments, as outlined early 
in this paper, could not be given. A few of the 
patients did receive the 1 : 500 dilution of the 
pollen extract two times, but for reasons already 
stated I consider this insufficient treatment. 

In Table 3 are presentel forty patients who 
were given insufficient treatment with ragweed 
pollen extract, and seven patients similarly 
treated with timothy pollen extract. The possi- 
bility of sensitization to pollens, that might 
be the cause of symptoms, other than ragweed 
[237] 



HAY-FEVER 

and timothy will not be considered in the light 
of previous discussion. The results were as fol- 
lows: Of the forty-seven patients in Table 3, 
none were free from symptoms, one was practi- 
cally free, seven were 75 per cent, benefited, 
twenty-five were 50 per cent, benefited, one was 
25 per cent, benefited and the remaining thirteen 
were not benefited. Therefore, altho a few 
patients may be from 50 to 75 per cent, bene- 
fited by as small a number as two treatments of 
the 1 : 500 dilution, these results are offset by the 
number of failures resultant from similar treat- 
ment, and this is still more evident when a 
smaller amount of treatment than two doses of 
the 1 : 500 dilution is given. The results shown 
in Table 3 verify what has already been proven 
in Tables 1 and 2, namely, that giving less than 
three preseasonal treatments with the 1 : 500 di- 
lution of pollen extract is undesirable. 

In table 4 are presented seventy -three patients 
who were treated with ragweed pollen extract 
two years in succession. Six patients were 
treated in the two seasons 1917 and 1918; fif- 
teen, in 1918 and 1919, and fifty-two in 1919 
and 1920. 

Analysis of Table 4 shows that for the first 
year of treatment, of the seventy-three patients, 
twenty-eight, or 38-f per cent., were free from 
symptoms; sixteen, or 22 per cent., were practi- 
cally free; fourteen, or 19+ per cent., were 75 
per cent, relieved; twelve, or 16.4 per cent., 
were 50 per cent, benefited, and three, or 4+ 
per cent., were not benefited. For the second 
[238] 



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Tests at 
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Number 
Treat- 
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1-100:3 
1-100:1 
1-500:4 
1-100:3 
1-500:4 


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Tests 
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[239] 



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o'O'* -e* -co -ot^oc^i^c^N 



OO'-i MMTftiO'£>t>.OOOSO'-<<NC»3'*iO<D 
i-HC^C< (N C^ (N M C^ IN <N C^ CO CO IM CO CO eO M 
CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO 



[240] 



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[241] 



25 

H 
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2 

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O'CiCCOtOtOtOOCOCOCO'— lOCDt^t^l^ 

cococococccocccocccocccocccocococo 



[242] 



FOEMS OF TREATMENT 

year of treatment, the results were: Of the 
seventy-three patients, twelve, or 16.4 per cent., 
were free from symptoms; sixteen, or 22 per 
cent., were practically free; thirty-three, or 45 
per cent., wer 75 per cent, relieved; nine, or 12 
per cent., were 50 per cent, relieved, and three, 
or 4-|- per cent., were not benefited. On compar- 
ing the results obtained from the first year's 
treatment with those obtained from the second 
year's treatment, it is noted that the same num- 
ber of patients were practically free from symp- 
toms both years, and that the number who were 
50 per cent, benefited were about the same for 
the year, but that there were 57 per cent, more 
all right the first year than the second year, and 
57 per cent, more that were 75 per cent, bene- 
fited the second year than the first. 

Altho the above results obtained by the 
first and second years' treatment do not differ 
markedly, yet this difference shows rather poorer 
results from the second year's treatment than 
from the first year's treatment, the opposite of 
what one would expect and desire. By compar- 
ing the amount of treatment that was given 
the first year with that given the second year 
it is evident that a diminished amount of treat- 
ment during the second year would seem to ex- 
plain the poorer results obtained during this 
year, and it may be stated, that, as a rule, it is 
desirable to give as much treatment with the 
final dilutions the second year, provided suffi- 
cient treatment is given the first year, and some- 
times less treatment is required. 
[243] 



HAY-FEVER 

Attention should be called to the few patients 
in Table 4 who were not benefited by treatment. 
Patient 311 was treated four times with the 
1 : 100 dilution of pollen extract the first year, 
and once with the same dilution the second year, 
and yet there was no benefit from treatment 
either year; altho this patient -was much 
worse during August and September, he did 
have symptoms throughout the year so that 
it is probable that there was some cause of 
hay-fever besides ragweed pollen. It is difficult 
to understand why Patient 314 should be 75 
per cent, benefited following seven treatments 
with a 1 : 500 dilution of pollen extract the first 
year and not benefited by four similar treat- 
ments the second year unless the failure was due 
to insufficient treatment the second year. There 
is no evident reason why Patient 316, who was 
similarly treated both years, was 75 per cent, 
benefited the first year and not benefited the 
second year ; neither is there an evident explana- 
tion why Patient 320, who was similarly treated 
both years, was not benefited the first year even 
tho at the end of treatment the skin test 
was negative with a 1 : 100 dilution of the pol- 
len, but was 75 per cent, benefited the second 
year. It happens that all of these failures oc- 
curred during the two years 1C18 and 1919, 
and both ragweed seasons, as already described, 
were very similar. None of these patients were 
sensitive to pollens other than ragweed • 

Fifty-seven skin tests were done at the end of 
treatment. In one case (335) the test was the 

[244] 



FOKMS OF TEEATMENT 

same at the end of treatment as before treat- 
ment, and the patient was only 50 per cent, bene- 
fited; a similar instance was noted in Table 1. 
Patient 348 gave a positive skin test with a 
1 : 1,000 dilution of the pollen extract both years 
at the end of treatment, but was 50 per cent, 
benefited the first year and was practically free 
from symptoms the second year. In the re- 
maining fifty-four tests, there was the usual 
diminished intensity of the reaction; in one- 
third of the cases, or those who had been treated 
with the 1 : 100 dilution of pollen extract, the 
skin test was positive in no dilution higher than 
1 : 100, and in some cases even this dilution was 
negative; in the remaining two-thirds of the in- 
stances no dilution higher than 1 : 500 gave a 
positive skin test at the end of treatment. The 
sensitivity of the patients was decreased from 
ten to one hundred times with an average de- 
crease of from twenty to fifty times. 

The conclusions resulting from Table 4 sub- 
stantiate all of those already mentioned, and 
the conclusion that one or more treatments with 
a 1 : 100 dilution produces the best results and 
the greatest reduction in the intensity of the 
skin test is likewise confirmed. 

In Table 5 are presented seven cases of early 
hay-fever treated two years in succession. Dur- 
ing 1918 and 1919, three patients were treated 
with grass pollen; during 1919 and 1920 three 
patients were treated with grass pollen, and 
during 1917 and 1918 one patient was treated 
with rose pollen. 

[245] 



HAY-FEVEE 

Patient 374, who was treated three times with 
a 1 : 500 dilution of timothy pollen extract, was 
75 per cent, benefited; what symptoms this 
patient had were present chiefly in early June. 
The second year, altho it was found that this 
patient was as sensitive to the pollen of June 
grass as to timothy, it was decided to treat him 
more strenuously with timothy pollen extract 
again since the first year's treatment with timo- 
thy was not deemed sufficient. Following two 
treatments with the 1 : 100 dilution of timothy 
pollen extract the second year, he was again 75 
per cent, benefited and again his chief symp- 
toms were manifested in June. Therefore, it is 
quite evident that since his chief symptoms were 
manifested in early June, previous to timothy 
pollination and during the pollination of June 
grass, to which he was very sensitive, that June 
grass was the cause of the symptoms, and that 
altho timothy treatment had not protected 
against June grass, it was really successful as 
far as timothy was concerned. During a third 
year, 1920, he was treated only with June grass 
pollen extract and had no symptoms during 
June grass pollination, but he did have consid- 
erable trouble during late June and July. In 
order to simplify the table this treatment is 
omitted. Therefore, there is no question 
that during the 1918 and 1919 seasons his 
25 per cent, of symptoms were caused by 
June grass pollen and that his timothy pol- 
len treatment was successful. Patient 375 
was treated four times each year with a 
[246] 



W 
< 

Q 

w 

H 

CO 

W 

O 
< 

w 

I 

n 
^ § 





^ 


















Resul 

of 
Treat 
ment 




ddd 




d 




t^t^ 




















:-H : 










ii 








:§ : 










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irH : 






















o 














TJ a 








:-H : 








%% 


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:§ : 








J2 ^ 










• rH I 








r 




































+-H : 










6j3 








88 : 






00 




Ho 
































2 




























C^ 


umber 

latments 

With 

Final 

ilution, 

imothy 


«>*•* 


9 

-100:1 
-100:5 
-100:3 


»> 


« " 




ZS QH 


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1 




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^ c 




■<1 




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[247] 









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i\t 



S: + 



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Ho 









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rH lO i-H 4) 



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[248] 



FOKMS OF TEEATMENT 

1 : 500 dilution of timothy pollen alone and 
was 75 per cent, benefited. Since this patient 
was not very sensitive to June grass and had no 
symptoms until timothy pollination, it is evi- 
dent that he had, as already shown, insufficient 
timothy treatment. Patient 376 was chiefly 
sensitive to tim^othy pollen and was free from 
symptoms following treatment with timothy pol- 
lent extract. 

Patients 377 and 378 were chiefly sensitive to 
timothy pollen extract the first year and were 
free from symptoms following treatment with 
timothy pollen alone. The second year they were 
equally sensitive to the pollens of both June 
grass and timothy, and were given less treat- 
ment than the preceding year with timothy 
pollen and a little treatment with June gra&s 
pollen extract; they were only 75 per cent, 
benefited the second year and their symptoms 
were manifested chiefly in late June and 
July. Therefore, treatment with the two 
pollen extracts together diminished the amount 
of treatment that they might have had with 
timothy alone, and the result was that both 
patients were only 75 per cent, benefited the 
second year ; furthermore, it is evident that they 
did not need June grass pollen treatment any 
way. The case of Patient 379 was similar to the 
two cases just discust, with the exception 
that this patient was equally sensitive to both 
pollens the first year as well as the second year, 
and that she was only 50 per cent, benefited the 
second year by treatment similar to that given 
[249] 



HAY-FEVER 

the two cases just cited; the fact that this pa- 
tient began treatment late, thus necessitating a 
five-day interval between treatments, may partly 
explain the poor results. 

Patient 373 was sensitive to the pollen of rose 
alone, and five and six treatments in 1917 and 
1918, respectively, prevented any symptoms both 
years even tho, since she was a nurse in a 
hospital, she had to be exposed freely to roses. 
Incidentally, it should be stated that previous to 
treatment, whenever she scratched her hands 
on rose thorns, marked itching and swelling re- 
sulted at the points of injury, but following rose 
pollen treatment these symptoms did not occur 
when injured by rose thorns. 

The conclusions to be drawn from Table 5 
verify those already proven correct in Table 2. 
The important conclusions are, that treatment 
with two pollens together is not advisable ; that 
the early type of hay-fever is chiefly due to 
timothy pollen, and sufficient treatment with 
timothy pollen alone, namely, treatment with 
the 1 : 100 dilution or its equivalent of a 1 : 500 
dilution, will give satisfactory results in such 
cases ; that this amount of treatment will usually 
markedly diminish the intensity of the skin test 
to timothy pollen, and that only an occasional 
case of early hay-fever is due to rose pollen. 
The correctness of the conclusion drawn from 
Table 4 that usually the patient needs as much 
treatment with the final dilutions the second year 
as he received the first year is also proven. 

In Table 6, twenty-five patients, who were 
[250] 



FOEMS OF TREATMENT 



treated three years in succession with ragweed 
pollen extract, are presented. During 1917 to 
1919 inclusive, five patients were treated, and 
during 1918 to 1920 inclusive, twenty were 
treated. 

Analysis of Table 6 shows that following the 
first year of treatment, a third of the patients 
were free from symptoms; one patient, or 4 

TABLE 6— PRESEASON AL TESTS AND TREATMENT WITH 
RAGWEED POLLEN THREE SUCCESSIVE YEARS 
G = Good. F = Fair. 











Season 1917 






Age 










Patient 


oi 


Dura- 










Onset 


tion 




Number 










Tests Before 


Treatments 


Result of 








Treatment 


with Final 
Dilution 


Treatment 


381 


38 


11 


1-1.000 ± 


1-100:1 


G. 


382 


15 


17 


1-10.000 zb 


1-500:3 


75% 


383 


20 


10 


1-5.000 db 


1-100:3 


G. 


384 


32 


10 


1-1.000 -f 


1-100:2 


G. 


385 


25 


8 


1-1.000 -f- 


1-100:3 
Season 1918 


G. 


386 


9 


3 


1-1,000 ± 


1-500:3 


G. 


387 


21 


5 


1-10,000 d= 


1-100:1 


1^1 

75% 


388 


28 


15 


1-5,000 ± 


1-500:3 


389 




23 


1-5,000 ± 


1-500:3 


390 


i7 


2 


1-1,000 ± 


1-500:2 




391 


1 


34 


1-5.000 + 


1-500:5 


75% 


392 


20 


20 


1-5,000 + 


1-100:2 


75% 


393 


27 


5 


1-5,000 ± 


1-500:3 


75% 


394 


12 


20 


1-5.000 ± 


1-500:4 


G. 


395 


11 


39 


1-5,000 ± 


1-500:3 


75% 


396 


21 


19 


1-5.000 + 


1-500:4 


G. 


397 


24 


20 


1-5.000 ± 


1-500:4 


P. 


398 


28 


10 


1-5.000 ± 


1-500:5 


50% 
50% 
75% 


399 


30 


25 


1-10.000 ± 


1-500:6 


400 


24 


10 


1-5.000 ± 


1-500:4 


401 


33 


16 


1-5,000 ± 


1-500:2 


402 


26 


8 


l-iOOOO± 


1-500:3 


403 


16 


2 


1-10,000 ± 


1-500:2 


50% 


404 


36 


6 


1-1,000 + 


1-100:4 


G. 


405 


8 


22 


1-1,000 + 


1-100:1 


G. 



[251] 



TABLE 6.— PRESEASONAL TESTS AND TREATMENT WITH 
RAGWEED POLLEN THREE SUCCESSIVE YEARS 
(Continued) 
G = Good. F = Fair. 





*of 


Dura- 


Season 1918 


Patient 




Number 








Onset 


tion 


Tests 


Treat- 


Tests 


Result 








Before 


ments 


After 


of 








Treat- 


With 


Treat- 


Treat- 








ment 


Final 
Dilution 


ment 


ment 


381 


38 


11 


1-1.000 rt 


1-100:4 




F. 


382 


15 


17 


1-10,000± 


1-500:3 




75% 


383 


20 


10 


1-5,000 ± 


1-500:5 




75% 


384 


32 


10 


1-1,000 ± 


1-500:4 




G. 


385 


25 


8 


1-1.000 ± 


1-100:1 

Season 


1919 


G. 


386 


9 


3 


1-500 ± 


1-100:6 


1-100.0 


G. 


387 


21 


5 


1-10.000 ± 


1-100:2 


1-100 -h 


F. 


388 


28 


15 


1-5,000 ± 


1-100:2 


1-100 + 


G. 


389 




23 


1-5.000 zb 


1-100:4 


1-100 + 


G. 


390 


17 


2 


1-5,000 ± 


1-100:5 


1-100 ± 


F. 


391 


1 


34 


1-5.000 -f 


1-500:6 




F. 


392 


20 


20 


1-10,000 + 


1-100:3 


i-Voo+ " 


G. 


393 


27 


5 


1-5.000 ± 


1-100:3 


1-100.0 


G. 


394 


12 


20 


1-5,000 ± 


1-100:1 


1-500 ± 


F. 


395 


11 


39 


1-5.000 + 


1-500:3 


1-500 + 


75% 


396 


21 


19 


1-5.000 -f 


1-500:4 


1-1,000 + 


F. 


397 


24 


20 


1-5.000 ± 


1-100:5 


1-100 + 


G. 


398 


28 


10 


1-5,000 ± 


1-500:5 




50% 


399 


30 


25 


1-5.000 4- 


1-500:3 


1-500+ ' 


75% 
75% 


400 


24 


10 


1-5.000 ± 


1-100:5 


1-100 + 


401 


33 


16 


1-5.000 ± 


1-500:5 


1-100 + 


75% 


402 


26 


8 


1-10,000 ± 


1-200:2 


1-100 + 


F. 


403 


16 


2 


1-10,000 ± 


1-500:5 




75% 


404 


36 


6 


1-1.000 -f 


1-100:4 




G. 


405 


8 


22 


1-1,000 ± 


1-500:4 




G. 



per cent., was practically free; a third was 75 
per cent, benefited, and six patients, or 24 per 
cent., were 50 per cent, benefited. Following 
the second successive year's treatment, ten pa- 
tients, or 40 per cent., were free from symptoms ; 
seven, or 28 per cent., were practically free; 
seven, or 28 per cent., were 75 per cent, bene- 
fited, and one patient, or 4 per cent., was 50 
[252] 



TABLE 6.— PRESEASONAL TESTS AND TREATMENT WITH 
RAGWEED POLLEN THREE SUCCESSIVE YEARS 
(Continued) 
G = Good. F = Fair. 





1,f 

Onset 


Dura- 
tion 


Season 1919 


Patient 


Tests 
Before 
Treat- 
ment 


Number 
Treat- 
ments 
with 
Final 
Dilution 


Tests 
After 
Treat- 
ment 


Result 

of 
Treat- 
ment 


381 
382 
383 
384 
385 

386 

387 
388 
389 
390 
391 
392 
393 
394 
395 
396 
397 
398 
399 
400 
401 
402 
403 
404 
405 


38 
15 
20 
32 
25 

9 
21 
28 

17 
1 
20 
27 
12 
11 
21 
24 
28 
30 
24 
33 
26 
16 
36 
8 


11 
17 
10 
10 
8 

3 

5 

15 

23 

2 

34 

20 

5 

20 

39 

19 

20 

10 

25 

10 

16 

8 

2 

6 

22 


1-1.000 db 
1-10.000 d= 
1-5.000 ± 
1-10.000 ± 
1-10,000 =b 

Pol + 
1-5.000 + 
1-10.000 ± 
1-1.000± 
1-5.000 ± 
1-5.000 ± 
1-5.000 -t- 
1-1.000 -f 
1-5.000 ± 
1-5.000 ± 
1-1.000 -f 
1-5.000 -+- 
1-5,000 ± 
1-20,000 ± 
1-5.000 ± 
1-5.000 ± 
1-5.000 ± 
1-10,000 ± 
1-1,000 -f 
1-500 ± 


1-500:4 
1-500:3 
1-500:5 
1-500:5 
1-500:5 

Season 
1-500:7 
1-500:5 
1-500:4 
1-500:5 
1-500:4 
1-500:5 
1-500:5 
1-500:5 
1-500:4 
1-500:6 
1-100:2 
1-500:4 
1-500:4 
1-500:5 
1-500:5 
1-100:1 
1-100:1 
1-100:2 
1-100:4 
1-500:6 


;;;;;;;; 

1920 
i-500± ' 

i-i'.6664- 
i-Y,666 + 

1-500 + ■ 
i-Yoo+ ' 

1-500 + 

i-i6o'.6' " 


F. 
75% 
75% 

F. 

F. 

F. 
F. 

75% 

75% 
75% 
50% 

F. 

F. 
75% 
50% 

?l 

75% 
G. 
G. 
G. 



per cent, benefited. Following the third suc- 
cessive year's treatment, three patients, or 12 
per cent., were free from symptoms; ten, or 
40 per cent., were practically free; ten, or 40 
per cent., were 75 per cent, benefited, and two, 
or eight per cent., were 50 per cent, benefited. 
There were no failures in any year. Seven of 
the twenty -five patients were either entirely free 
[253] 



HAY-FEVER 

or practically free from symptoms all three 
years. 

A comparison of the results of the three years ' 
treatments with the amount of treatment given 
to each patient each year substantiates previous 
conclusions : ( 1 ) Treatment with the 1 : 100 di- 
lution yielded by far the best results; (2) five 
or six doses of the 1 : 500 dilution was followed 
by excellent results; (3) three or four doses of 
the 1 : 500 dilution sometimes was followed by 
excellent results but more often by 75 per cent, 
benefit, and (4) two doses of the 1: 500 dilution 
gave poor results. 

In twenty-two instances skin tests were done 
at the end of treatment. Following treatment 
with the 1 : 100 dilution of pollen protein, in two 
instances the 1 : 100 dilution was negative ; in 
nine instances the 1 : 100 dilution gave a doubt- 
ful to a positive reaction, and in only two in- 
stances was the 1 : 500 dilution at all positive. 
Following treatment with the 1 : 500 dilution, in 
one instance the 1 : 100 dilution was somewhat 
positive ; in four instances the 1 : 500 dilution 
was more or less positive, and in three instances 
the 1 : 1,000 dilution was positive. Two of those 
that were positive with the 1 : 1,000 dilution 
were treated four times with the 1 : 500 dilution, 
and two of those that were positive with the 
1 : 500 dilution were given only three doses of the 
1 : 500 dilution. Therefore, as shown repeatedly, 
there is nearly always a great decrease in the 
sensitivity of the patient, as evidenced by the 
skin test, following considerable treatment, and 

[254] 



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[257] 



HAY-FEVER 

the greatest decrease results from treatment 
with the 1 : 100 dilution. 

In Table 7 are presented four patients with 
early hay-fever who were treated three years in 
succession with the grass pollens. The four 
patients were either free or practically free from 
symptoms following treatment with timothy pol- 
len alone the first year, and all were entirely free 
from symptoms following an increased amount 
of timothy pollen treatment the second year, 
even tho two of the patients were equally 
sensitive to redtop pollen and quite sensitive to 
June grass pollen. Therefore, as already proven, 
timothy pollen treatment will protect against 
redtop pollen and there was no evidence that the 
patients needed June grass pollen treatment. 
From the experience of the first two years, there 
was every reason to believe that similar timothy 
pollen treatment alone would ensure excellent 
results the third year. Therefore, it was de- 
cided to make an experiment of these four cases 
by treating three of them with varying amounts 
of June grass pollen together with sufficient 
timothy treatment, and to treat the fourth pa- 
tient with timothy pollen alone as a control. 
The results were interesting, in that the first 
patient who had the maximum treatment with 
both pollen extracts was only 50 per cent, bene- 
fited; the second patient who had maximum 
treatment with timothy pollen, and considerable, 
tho less, treatment with June grass pollen, 
was 75 per cent, benefited, whereas the third 
patient, who had considerable, tho less, treat- 

[258] 



FOEMS OF TEEATMENT 

ment with timothy pollen than the other two 
patients, but who had as much treatment with 
June grass pollen, was free from symptoms, and 
the fourth patient, following treatment with 
timothy pollen extract alone, was also free from 
symptoms. Therefore, the only difference in the 
treatment of the first three cases between the 
first two years and the third year was the addi- 
tional treatment with June grass pollen in the 
third year. The greater the amount of treat- 
ment with June grass pollen extract, the poorer 
were the results, and the same number of treat- 
ments with June grass pollen in a non-sensitive 
case and no June grass treatment in a non- 
sensitive case was followed by excellent results. 
In order to give the first patient three treat- 
ments with the 1 : 100 dilution of pollen extract, 
this treatment was carried on in increasing large 
doses during June grass pollination so that the 
patient was being treated by and at the same 
time was being exposed to June grass pollen, 
and the result was that the patient had much 
hay-fever during June as a result of treatment 
with large doses of June grass pollen at the 
time of natural exposure to the pollen, altho 
in the previous two years he either was not 
sufficiently exposed to June grass pollen or he 
had sufficient protection against it. The second 
patient was comparable with the first, with the 
exception that the June grass pollen treatment 
was discontinued shortly after the onset of June 
grass pollination, but timothy pollen treatment 
was continued as in the first case. Therefore, 

[259] 



TABLE 8.— PRESEASONAL TESTS AND TREATMENT WITH 
RAGWEED POLLEN FOUR SUCCESSIVE YEARS 

G = Good. F = Fair. N = None. 





Age of 
Onset 


Dura- 
tion 


Season 1917 


Patient 


Tests 

Before 

Treatment 


Number 
Treatments 
with Final 

Dilution 


Result 

of 
Treat- 
ment 


406 
407 
408 
409 


5 
31 
21 
15 


42 
16 
20 
45 


1-1.000 ± 
1-1.000 ± 
1-5.000 ± 
1-5.000 ± 


1-100:4 
1-100:3 
1-100:3 
1-500:3 


G. 
50% 



TABLE 8.— PRESEASONAL TESTS AND TREATMENT WITH 
RAGWEED POLLEN FOUR SUCCESSIVE YEARS 
(Continued) 
G = Good. F = Fair. N = None. 





Age of 
Onset 


Dura- 
tion 


Season 1918 


Patient 


Tests 

Before 

Treatment 


Number 
Treatments 
with Final 

Dilution 


Result 

of 
Treat- 
ment 


406 
407 
408 
409 


5 
31 
21 
15 


42 
16 
20 
45 


1-100 ± 
1-1.000± 
1-5.000 ± 
1-5.000 i 


1-100:4 
1-500:4 
1-500:5 
1-500:5 


75% 
50% 



the second case had less treatment during June 
grass pollination and had less symptoms in June 
SO that the result was 75 per cent, benefit. The 
third patient had as much June grass treatment 
but was not sensitive to June grass pollen, there- 
fore, June grass treatment during its pollination 
was harmless and needless as it would have been 
had it been given to the fourth patient. 

The manner in which June grass pollen was 
[260] 



TABLE 8.— PRESEASONAL TESTS AND TREATMENT WITH 

RAGWEED POLLEN FOUR SUCCESSIVE YEARS 

(Continued) 

G = Good. F = Fair. N = None. 





Age of 
Onset 


Dura- 
tion 


Season 1919 


Patient 


Tests 

Before 

Treatment 


Number 
Treatments 
with Final 

Dilution 


Result 

of 
Treat- 
ment 


406 
407 
408 
409 


5 
31 
21 
15 


42 
16 
20 
45 


1-500 -f 
1-1, 000 ± 
1-5.000 ± 
1-5.000 d= 


1-100:4 
1-100:2 
1-500:5 
1-500:2 


75% 
G. 



TABLE 8.— PRESEASONAL TESTS AND TREATMENT WITH 

RAGWEED POLLEN FOUR SUCCESSIVE YEARS 

(Continued) 



G = Good. F = Fair. N = None. 





Age of 
Onset 


Dura- 
tion 


Season 1920 


Patient 


Tests 

Before 

Treatment 


Number 
Treatments 
with Final 

Dilution 


Result 

of 
Treat- 
ment 


406 
407 
408 
409 


5 
31 
21 
15 


42 
16 
20 
45 


1-500 ± 
1-1,000 + 
1-10,000 ± 
1-10.000 + 


1-100:3 
1-500:4 
1-500:6 
1-500:5 


75% 

75% 
G. 



given to the patients in Table 7 differs from the 
way it was given in the preceding tables in that 
in these cases treatment with June grass was 
discontinued before the onset of its pollination, 
whereas, the patients in Table 7 were treated 
with gradually increasing amounts of June grass 
pollen during the time the patients were being 
naturally exposed to the pollen. Therefore, 
treatment with large amounts of a pollen ex- 
[261] 



1 



HAY-FEVER 

tract during the season of its pollination is evi- 
dently not desirable. The conclusion that has 
already been repeatedly stated, namely, that 
mixed pollen treatment is, as a rule, not only un- 
necessary but undesirable, was equally true of 
cases in Table 7, and the poorer results obtained 
in the third successive year of treatment was 
due, as shown repeatedly, to mistreatment. 

In Table 8 are presented four patients who 
were treated with ragweed pollen extract four 
successive years. 

They illustrate the slightly variable results 
that may be obtained by giving similar treat- 
ment each year to the same patient for several 
years, and by giving varying amounts of treat- 
ment to the same patient for several years. 

In three of these cases the results exprest 
on a percentage basis were practically identical 
for all four years and the only exception to this 
in the fourth patient was the unfavorable re- 
sult that followed too little treatment in the 
third year. In other words, favorable results 
may be looked for following any number of suc- 
cessive years' treatment, provided the average 
number of treatments are given each year. No 
matter how many successive years the same pa- 
tient is treated, as a rule, approximately the same 
amount of treatment with the final dilution is re- 
quired each year as that which gave desirable re- 
sults any preceding year, however, no greater 
amount of treatment is required in successive 
years than that which gave desirable results any 
preceding year. 

[262] 



( 



FOEMS OF TEEATMENT 

During -the- Season or Curative Treatment 
with Pollen. — Frequently patients present them- 
selves for treatment during their hay-fever at- 
tack, and altho pollen treatment at this time 
does not seem to be very logical, on the basis of 
anaphylaxis, the patient often will insist on 
taking the chance. Pollen treatment during the 
season does not seem logical because the patient 
is being injected with the pollen which is caus- 
ing symptoms at the same time that he is being 
exposed to the pollen present in the air which 
he is inhaling. The danger resulting from large 
doses of the injected pollen is obvious because of 
an overdose, due to the combination of the in- 
jected pollen and the inhaled pollen. Therefore, 
in order that during-the-season treatment should 
be beneficial, the patient must be injected with 
minute amounts of the pollen extract in order 
to diminish artificially a few of the patients 
antibodies, thus leaving a smaller number of 
antibodies in the patient for combination with 
the pollen antigen that is inhaled. If too much 
pollen extract (antigen) is injected, the patient 
should have symptoms due to over-treatment 
alone, or he should be made worse, due to the 
injection of pollen extract (antigen) superim- 
posed on the inhalation of pollen (antigen). It 
is evident, that on the basis of anaphylaxis, dur- 
ing-the-season treatment is hazardous, and 
altho the skin test is the best guide as to 
the proper treatment, there is no way of con- 
trolling the amount of pollen that the patient 
may inhale. 

[263] 






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[265] 



HAY-FEVER 

In Table 9 are presented twenty-two patients 
who were treated wdth grass pollens during the 
season of their pollination, and while they were 
having symptoms from exposure to these pollens. 
Three patients were treated in 1917 with timothy 
pollen; in 1919, six were treated with timothy, 
and one was treated with June grass, and in 
1920, nine were treated with timothy, two with 
the combination of timothy and June grass, and 
one with June grass alone. 

Before considering Table 9, it may be well 
to explain the notations beneath the headings of 
each column, using the first patient as an ex- 
ample. Four hundred and fifteen is the sequence 
number of the patient in the whole series pre- 
sented in this paper. No. 374 in the second 
column means that this same patient has been 
presented previously in this paper, and on re- 
ferring back, it is seen that this patient was pre- 
sented in Table 5 which consisted of patients who 
were treated with grass pollen two years in suc- 
cession; in other words as No. 415 the patient 
was treated during the season in 1917 (Table 
9) and preseasonally two successive years, 1918 
and 1919 (Table 5). The third column gives 
the skin test. The next column gives the dates 
of treatment, that is June 22 to July 12, inclu- 
sive. The treatment column gives the dilutions 
with which the patient was treated and the 
respective amounts of each treatment dilution 
in cubic centimeters ; for instance 1 : 20,000 dilu- 
tion of timothy pollen extract, dose 0.15 c.c, 
then 0.3 c.c, after this the 1 : 10,000 dilution, 
[266] 



FORMS OF TREATMENT 

dose 0.15 and 0.15 c.c. The five or seven day 
interval between doses is understood, and usually 
the same scheme of treatment was followed as 
outlined in the first part of this paper for pre- 
seasonal treatment, and the skin test was used as 
the guide to determine the initial dose. The last 
column gives the result from during-the-season 
treatment, for instance, the first patient was 75 
per cent, benefited. 

The results from during-the-season treatment 
were: Of the twenty-two patients treated, none 
were free from symptoms ; seven, or 32 per cent., 
were practically free; four, or 18+per cent., 
were 75 per cent, benefited; three, or 13+per 
cent., were 50 per cent, benefited; the same 
number were 25 per cent, benefited, and five, 
or 22-1-per cent., were not benefited. Since no 
patients were entirely relieved of symptoms, and 
since a large percentage were not benefited, it 
is evident, on comparing these results with those 
of former tables, that preseasonal treatment 
ensures better results by far than does during- 
the-season treatment. If preseasonal treatment 
is absolutely barred, during-the-season treat- 
ment is worth trying, provided it is given with 
sufficient care and the skin test is used as a guide 
to the initial treatment. 

Patients 442 and 454 were treated with June 
grass (J. G.) alone because they were sensitive 
to this pollen only, and were having symptoms 
during June grass pollination, as noted by the 
dates of treatment, namely, from the last of 
May to the middle of June. Patients 451 and 
[267] 



HAY-FEVER 

453 were treated with the combination of tim- 
othy and June grass pollen extracts because 
they were having symptoms and were sensitive 
to June grass, and they were also sensitive to 
and had had symptoms during the timothy 
pollination. The other patients were treated 
with timothy pollen extract alone, because prac- 
tically all of them were first seen at the end of 
June grass pollination and at the beginning or 
during timothy pollination. 

With three of the patients we have the op- 
portunity of contrasting during-the-season treat- 
ment with preseasonal treatment. Patient 415 
was 75 per cent, benefited by during-the-season 
treatment, and he was similarly benefited by 
preseasonal treatment in the two following years 
(Table 5, Patient 374). Patient 445, who was 
75 per cent, benefited by during-the-season treat- 
ment, was free from symptoms following pre- 
seasonal treatment (Table 2, Patient 208). Pa- 
tient 446, who was 75 per cent, benefited from 
during-the-season treatment, was similarly bene- 
fited following preseasonal treatment (Table 2, 
Patient 205), and was not benefited following 
the same amount of preseasonal treatment (Ta- 
ble 3, Patient 286) as was given during the 
season. It is not advisable to draw general con- 
clusions from these three cases, altho they 
are of sufficient interest to warrant mention. 

In Table 10 are presented twenty-seven pa- 
tients who were treated with ragweed pollen ex- 
tract during the season. The notations in this 
table are exactly like those in Table 9, therefore 

[268] 



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[270] 



FOEMS OF TEEATMENT 

no explanation is needed. It should be stated, 
however, that these patients were tested with and 
found to be either not sensitive or only slightly 
sensitive to other pollens. 

Of the twenty-seven patients presented in 
Table 10, three, or 11 + per cent., were free 
from symptoms ; one patient, or 3 + per cent., 
was practically free ; three patients, or 11 + per 
cent., were 75 per cent, benefited ; seven, or 25 + 
per cent., were 50 per cent, benefited; one pa- 
tient, or 3 + per cent., was 25 per cent, bene- 
fited, and twelve patients, or 44 + per cent., 
were not benefited. Therefore, altho a few 
patients were free from symptoms, and as many 
more were 75 per cent, benefited, the number 
who were only 50 per cent, benefited was as 
great as the number who were more than 50 per 
cent, benefited, and nearly half of the whole 
series were not benefited at all. On comparing 
these results from during-the-season treatment 
with the results presented in former tables from 
preseasonal treatment, it is evident that for late 
hay-fever by far the best results are obtained 
from preseasonal treatment, and it is question- 
able whether during-the-season treatment is even 
worth giving when it is taken into consideration 
that there are localities to which patients may 
go where ragweed does not exist. 

Since fifteen of these patients have been dis- 
cust elsewhere in this paper, it is possible 
with these to compare during-the-season treat- 
ment with preseasonal treatment. Ten of the 
patients were presented in Table 1, therefore 
[271] 



HAY-FEVEE 

it is possible to contrast the results from the 
two kinds of treatment in these cases with little 
detail. Patient 417 (35a) was free from symp- 
toms following preseasonal treatment and 75 
per cent, benefited from during-the-season treat- 
ment; Patient 419 (36) was free from symp- 
toms following" preseasonal and practically free 
from symptoms from during-the-season treat- 
ment; Patient 428 (59) was 50 per cent, bene- 
fited as a result of both kinds of treatmxcnt; 
therefore, in these three cases the results from 
preseasonal treatment were slightly better than 
those from during-the-season treatment in two 
of them, and the same in the third case. The 
other seven cases in this group, namely, Patients 
422 (119), 427 (6), 431 (61), 435 (84), 439 
(184), 447 (10) and 449 (62) were not bene- 
fited by during-the-season treatment, but fol- 
lowing preseasonal treatment three were free 
from symptoms, one was practically free, two 
were 75 per cent, benefited and the remaining 
patient was 50 per cent, benefited. Therefore, 
in these seven cases during-the-season treatment 
was a failure, whereas preseasonal treatment 
gave very satisfactory results. Since the remain- 
ing five patients in Table 10, that have been 
presented elsewhere, were all presented in Table 
4, they may be considered together with Little 
detail. Patient 426 (372) was 50 per cent, bene- 
fited by during-the-season treatment, and was 50 
per cent, and 75 per cent., respectively, bene- 
fited the two seasons during which he was pre- 
seasonally treated; Patient 435 (370) was free 
[272] 



FOEMS OF TEEATMENT 

from symptoms from dnring-the-season treat- 
ment and was free from symptoms and 75 per 
cent, benefited the two respective seasons fol- 
lowing preseasonal treatment ; therefore, in these 
two cases, the results from both kinds of treat- 
ment were very similar. Patients 425 (371), 
432 (346) were not benefited at all by during- 
the-season treatment, whereas following presea- 
sonal treatment two successive j^ears, Patient 425 
(371) was free from symptoms and 75 per cent, 
benefited, Patient 432 (346) was 75 per cent, 
benefited both years. Patient 433 (369) was 
practically free and 75 per cent, benefited. With 
these three cases, therefore, during-the-season 
treatment was a failure, whereas preseasonal 
treatment was very satisfactory. 

From these fifteen patients who were treated 
both ways it may be noted that frequently dur- 
ing-the-season treatment gives as good results as 
preseasonal treatment. This was true in five, 
or one-third, of the cases. However, more often 
during-the-season treatment is a failure in the 
same cases in which preseasonal treatment is 
very satisfactory. This was true in ten, or two- 
thirds, of the cases. These conclusions also 
verify what was stated in the second preceding 
paragraph, namely, that for late hay-fever by 
far the best results are obtained from presea- 
sonal treatment than from during-the-season 
treatment. 

In Table 11 are presented nineteen patients 
who were treated with bacterial vaccines during 
their hay-fever attack, altho they were very 
[273] 



HAY-FEVER 

sensitive to ragweed pollen and were having 
hay-fever symptoms during ragweed pollination. 
The reason for such treatment was that it is 
quite possible that ragweed pollen exposure may 
in some cases cause such a severe irritation of 
the mucous membranes that ever-present bac- 
teria may, either alone or together with ragweed 
pollen, be a cause of hay-fever symptoms. In 
our study on pollen asthmatics^ this was found 
to be the case in many instances, and Frank 
and Strouse," Medalia," Scheppegrell " and 
others, have considered this to be true in hay- 
fever cases. The construction of Table 11 differs 
from that of Tables 9 and 10 in only two ways, 
namely, that treatment was given with bacterial 
vaccines, and that the numerals under the treat- 
ment column represent that many hundred mil- 
lions of bacteria per dose. In some instances, 
the vaccine used was an autogenous one made 
from the patient's nasal secretions; in other in- 

•Walker, I. C. — Sensitization and Treatment of 
Bronchial Asthmatics with Pollens, Am. J. M. Sc. 
157:409, 1919. 

•Frank, I., and Strouse, S. — Pollen Extracts and 
Bacterial Vaccines in Hay-Fever, J. A. M. A. 72:1593 
(May 31) 1919. 

"Medalia, L. S. — Hay-Fever; Its Treatment with 
Autogenous Vaccines and Pollen Extract, Boston M. & 
S. J. 175:201, 1916. 

"Scheppegrell, W. — Anaphylaxis Due to Pollen Pro- 
tein, with a Report of the Results of Treatment in 
the Hay-Fever Clinic of the New Orleans Charity 
Hospital, Laryngoscope 28:853, 1919. 
[274] 






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[275] 



HAY-FEVER 

stances it was a stock vaccine consisting of 
Staphylococcus pyogeij^oiis aureus or S. albus; 
and, for those patients who were treated in 1920, 
a mixed streptococcus vaccine was used. This 
mixed streptococcus vaccine consisted of equal 
amounts of the six streptococci that were most 
frequently found in the sputum and nasal secre- 
tions of asthmatic patients." These streptococci, 
according to Holman 's classification, were hemo- 
lytic types S. pyogenes, S. infrequens and S. 
ang'inosiis and non-hemolytic types S. salivarlus, 
S. ignavus and S. miiis in the proportion of 
approximately sixteen million of each per one 
hundred million of total, so that a dose of 300 
million mixed streptococci represented about 
fifty millions of each of the six strains. 

Since Patients 466, 469, 474, 475, 477, 478 
and 479 had not been previously observed or 
treated by me, their cases will be considered 
together and not too much stress will be placed 
on the results. Patient 466 was 50 per cent, 
benefited and Patient 469 was not benefited by 
treatment with autogenous vaccines made from 
the nasal secretions. Patients 474 and 478 were 
50 per cent, benefited, and Patient 477 was 25 
per cent, benefited by the mixed streptococcus 
vaccine. Patients 475 and 479 were not bene- 
fited by the mixed streptococcus vaccine. The 
only conclusion to be drawn from these cases 

"Walker, I. C, and Adkinson, J. — Types of Strepto- 
cocci Found in the Sputum of Bronchial Asthmatics, 
J. M. Eesearch 40:229, 1919. 
[276] 



FOEMS OF TEEATMENT 

is that sometimes an autogenous nasal vaccine 
or a mixed streptococcus vaccine given during 
the hay-fever attack benefits somewhat an oc- 
casional patient but just as often this treatment 
fails. 

The twelve following patients, however, since 
they were treated with ragweed pollen either 
during or preceding the ragweed season in some 
vear, give more definite information. Patients 
464 (184 and 439) and 472 (187) were relieved 
of symptoms while being treated with their auto- 
genous nasal secretion vaccine, whereas both 
patients were only 50 per cent, benefited from 
preseasonal pollen treatment (Table 1, Patients 
184 and 187) and one patient was not benefited 
at all by during-the-season pollen treatment 
(Table 10, Patient 439). In these two control 
cases it may be assumed that bacteria played 
some part, at least, in the cause of symptoms. 
Since Patients 468 (11), 471 (385), 473 (463) 
and 476 (10) were not benefited by vaccine 
treatment but all had been free from symptoms 
from ragweed pollen treatment, it is certain that 
bacteria played no part in the causation of their 
hay-fever symptoms. These four patients had 
been treated with ragweed pollen extract: Pa- 
tients 468 (11) and 476 (10), preseasonal one 
year and were free from symptoms (Table 1, 
Nos. 10 and 11) ; Patients 471 (385), preseasonal 
three years in succession and was free from 
sym.ptoms two years and practically free the 
third year (Table 6, No. 385) ; Patient 473 (463) 
treated during the season was free from symp- 
[277] 



HAY-FEVER 

toms (Table 10, No. 462). Patient 465 who was 
not benefited by either Staphylococcus pyogenes 
albus vaccine or by too little preseasonal treat- 
ment (Table 3, No. 264), and was only 50 per 
cent, benefited by considerable preseasonal treat- 
ment (Table 1, No. 181) gives no information 
with the exception that Staphylococcus pyogenes 
albus played no part in the causation of hay- 
fever symptoms in this case ; this same organism 
was used in two cases already discust. Pa- 
tients 468 and 471, with no benefit. Patients 
480 (186) and 482 (154) both became practically 
free from symptoms during mixed streptococcus 
vaccine treatment, whereas from preseasonal 
pollen treatment both were benefited only 75 
per cent. (Table 1, Nos. 186 and 154) ; there- 
fore, in these two cases streptococci probably 
played a considerable part in the causation of 
hay-fever symptoms. Patient 470 (185) was 75 
per cent, benefited during treatment with 
Staphylococcus pyogenes aureus vaccine, whereas 
only a 50 per cent, benefit followed preseasonal 
pollen treatment (Table 1, No. 185), therefore 
Staphylococcus pyogenes aureus probably played 
some part in the causation of hay-fever symp- 
toms in this case. Patient 481 (108) was 50 
per cent, benefited during mixed streptococcus 
vaccine treatment, but was not improved by pre- 
seasonal pollen treatment (Table 1, No. 108) ; 
therefore, in this case it is quite evident that 
streptococci played a part in the causation of 
hay-fever symptoms. 

The series of patients who were treated with 
[278] 



FOEMS OF TEEATMENT 

bacterial vaccines is too small to justify sweep- 
ing conclusions, however, it does seem as tho 
treatment with bacterial vaccines were beneficial 
for a few hay-fever patients who are very sensi- 
tive to pollen. If a vaccine is to be used, the 
choice of bacteria would seem to be either an 
autogenous nasal or a mixed streptococcus vac- 
cine. In the few cases in which considerable 
preseasonal pollen treatment is not very satisfac- 
tory, it is worth while to try during-the-season 
treatment with autogenous nasal secretion or a 
mixed streptococcus vaccine. 

In Table 12 are presented eighteen patients 
who were treated with ragweed pollen both pre- 
ceding and during the season. The first nine 
patients were given the usual preseasonal pollen 
treatment and then this treatment was discon- 
tinued. A little later, during the same season, 
these patients reported that they were having 
more or less hay-fever so that during-the-season 
treatment with pollens was then given as de- 
scribed in Table 10; in other words, the two 
methods of treatment were given to these pa- 
tients. The other nine patients were treated 
with gradually increasing doses of the pollen ex- 
tract, but the treatment was begun so late pre- 
seasonally that not enough treatment would have 
been given had treatment been discontinued 
at the onset of pollination ; therefore, the usual 
preseasonal treatment, using gradually increas- 
ing doses, was continued on through the season 
of pollination. For example. Patient 492 was 
treated with gradually increasing amounts of 

[279] 



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[280] 



FOEMS OF TREATMENT 

ragweed pollen extract from July 18 to Septem- 
ber 10 inclusive; the usual preseasonal treat- 
ment was begun preseasonally and continued 
into or through the season of pollination. 

Patients 483 and 489 were not benefited by 
preseasonal treatment (Table 1, Nos. 14 and 
33) ; they were then given during- the-season 
treatment, as indicated in Table 12, with the 
result that they were 50 per cent, benefited. 
Patients 485 and 491 were benefited 75 and 50 
per cent., respectively, following preseasonal 
treatment (Table 1, Nos. 18 and 35) ; they were 
then given during-the-season treatment, as in- 
dicated in Table 12, with no apparent change 
in their symptoms. Patients 484, 486, 488 and 
490 were all unimproved by during- che-season 
treatment following the preseasonal treatment 
(as indicated in Table 4, Nos. 308, 314, 317 and 
320) which in two cases failed to benefit and in 
the two others there was a 50 per cent, benefit. 
The remaining patient (487 was not as much 
benefited while being treated during the season 
as he had been by preseasonal treatment) (Table 
6, No. 399). Therefore, in only two of these 
nine cases did during-the-season treatment im- 
prove the results already obtained from pre- 
seasonal treatment, but since these two patients 
were not benefited by preseasonal treatment 
(Table 1, Nos. 14 and 33) and became 50 per 
cent, benefited by during-the-season treatment, 
the latter treatment was worth tryins: after the 
former had failed ; in other words, two failures 
were changed to 50 per cent, benefit. 
[281] 



HAY-FEVER 

The remaining nine patients were treated ac- 
cording to the pre-season schedule, but treat- 
ment was begun very late (in July) and con- 
tinued into the hay-fever season. Altho this 
is the first time this method of pollen treatment 
has been mentioned in this paper, it has been 
used extensively in the past by many investiga- 
tors. The results from this method of treatment, 
as indicated in Table 12, show that no patients 
were entirely free from symptoms; one patient, 
or 11 per cent., was practically free; one-third 
of the patients were 75 per cent, benefited; 44 
per cent, were 50 per cent, benefited, and one 
patient, or 11 per cent., was not benefited. Of 
course, this series of cases is much too small 
to warrant conclusions, yet it would seem fair 
to say that this method of treatment is prefer- 
able to during-the-season treatment alone but 
not as desirable as the regular preseasonal treat- 
ment which is begun early enough to permit of 
its discontinuance just prior to the season of 
pollination. 

Hay -Fever Caused By the Pollen of Trees. — 
So far in this paper we have been concerned with 
the two pollen seasons, namely, August and 
September (ragweed) and May to August (the 
grasses). There is a third and earlier pollen 
season which begins in March and continues 
into June, during which time various trees pol- 
linate. Silver maple often pollinates in Febru- 
ary ; the other maples, birches, willows and hazel 
nut pollinate in late March or early April; 
the poplars, juniper, cottonwood and elm poUi- 
[282] 



FOEMS OF TEEATMENT 

nate during April ; the oaks, ash, bayberry and 
hickory pollinate during May ; the pines pollinate 
in late May and early June, and the fruit trees 
pollinate in May. I have observed twelve patients 
who were sensitive to and had hay-fever from the 
pollen of trees. One patient had hay-fever 
caused by the pollen of apple-blossoms, and he 
was free from symptoms following preseasonal 
treatment with its pollen extract. One patient, 
who was sensitive to the pollen of the oak and 
maple, and another, who was sensitive to the 
pollen of the willow, were both free from symp- 
toms following preseasonal treatment with these 
pollen extracts. Patients not treated were those 
sensitive to the following tree pollens; one pa- 
tient, to poplar tree pollen; one, to pine tree 
pollen; two, to ash; one, to willow; two, to 
both willow and poplar, and one to willow, 
poplar and ash. Since the season of pollination 
of the individual trees continues only from a few 
days to two weeks at the most, it does not seem 
essential that treatment be given. 

Other Pollens that May Cause Hay-Fever. — 
It has been shown in this paper that the chief 
causes of hay-fever occurring in the New Eng- 
land States were the pollens of ragweed, timothy 
and June grass; that an occasional cause is the 
pollen of the rose and redtop grass and of vari- 
ous trees. There is, however, almost an unlimited 
list of pollens that may at any time, but prob- 
ably rarely, cause hay-fever. Therefore, for 
those who treat a large number of hay-fever 
patients and for those who fail to obtain satis- 

[283] 



HAY-FEVEE 

factory results from treatment with the common 
pollens mentioned, it is advisable to have a very- 
extensive assortment of pollens. As a rule, how- 
ever, it would seem to be sufficient to warn the 
ragweed patients that they should not smell of 
goldenrod, golden-glow, sunflower, poppy, aster, 
chrysanthemum and the like that pollinate dur- 
ing the ragweed season. The grass cases may be 
warned to avoid close contact with clover, lilies, 
daisy, dandelion, rose, lawn grass, orchard grass, 
corn and the like that pollinate during the grass 
season. In certain localities in this country it 
may be necessary to treat with the pollen ex- 
tracts of the various grains, with sunflower or 
what not, but this necessity is not universal and 
is limited to the various localities where ex- 
posure to these particular pollens is unavoidable. 

Other Parts of Plants that May Cause Hay- 
Fever. — The leaves of certain plants and trees 
may cause hay-fever. The under surface of 
some leaves has a fine hairy growth, and these 
fine hairs may cause hay-fever. I have observed 
one patient who had hay-fever from and was 
sensitive to the hairs of the willow tree leaf; 
treatment with an extract of these leaves pre- 
vented hay-fever. Another patient was sensi- 
tized to and had hay-fever from the plantain 
leaf. It is quite probable that the plane tree, the 
common shade tree in London, may cause hay- 
fever. Such instances, however, are extremely 
rare and need not be considered, as a rule. 

Foods May Cause Seasonal Hay-Fever, — Sea- 
sonal hay-fever, due primarily to foods, has not 
[284] 



FOEMS OF TEEATMENT 

come to my notice. However, during their sea- 
son many hay-fever patients find that certain 
foods aggravate their symptoms, whereas these 
same foods may be eaten without symptoms at 
a time when they are not accustomed to have 
hay-fever, and they can eat the foods during 
their hay-fever season, provided they have had 
sufficient pollen treatment to protect them 
against the particular pollen that primarity 
causes their hay-fever. These foods are usually 
the fruits, and they have no apparent relation- 
ship to the causative pollen. Among the usual 
fruits should be mentioned peach, melon and 
apple. Green corn and the use of beer and wine 
often aggravate ragweed hay-fever, but they do 
not aggravate grass pollen hay-fever as one 
would expect to be the case; celery sometimes 
acts similarly. With the peach it is often the 
skin that causes trouble, whereas the pulp usu- 
ally does not. The cooking of the fruits often 
renders them inert. 

Animal Emanations May Cause Seasonal Hay- 
Fever. — The patient who is sensitive to animal 
emanations usually has symptoms on e:5tposure 
to the animal at any and all times of the year; 
occasionally, however, such a patient has symp- 
tomps only from exposure to the animal during 
the spring and summer, when the animal is shed- 
ding, moulting or perspiring profusely. 

Bacteria May Cause Seasonal Hay Fever. — 
The possibility of bacterial infection as a com- 
plication of or secondary to pollen sensitization 
has already been, discust, and the possibility 
[285] 



HAY-FEVER 

of bacterial infection as a primary cause of hay- 
fever in patients who are not sensitive to pol- 
lens must be considered. Each year I examine 
three or four patients who have seasonal hay- 
fever, but who are not sensitive to any of the 
pollens ; therefore, these patients are treated with 
their autogenous nasal secretion vaccine. 

REPORT OF CxiSES 

Case 1. — ^L. W., a woman, aged 35, has had 
hay-fever from August first to the end of Octo- 
ber for three years. Her symptoms are sneezing, 
running of the nose and some wheezing. 

Not only were the skin tests with pollens nega- 
tive, but she also failed to give an ophthalmic 
test, and snuffing the whole pollen of ragweed 
and dropping a concentrated solution of ragweed 
pollen extract into her nose failed to provoke 
symptoms. 

The patient was treated with an autogenous 
vaccine, made from her nasal secretion, in gradu- 
ally increasing amounts, beginning with 300 
million streptococci, from June 25 to Oct. 11, 
1919. At the end of the season, she reported 
that in previous summers she had always lost 
three weeks of sleep, whereas during the past 
summer she had lost only one week of sleep, and 
that her days had been quite free from symp- 
k)ms. 

In June, 1920, she reported that her hay- fever 
had begun about three weeks previously. She 
was again treated as previously, from June 7 
[286] 



FOEMS OF TEEATMENT 

to July 12, when she discontinued treatment be- 
cause she had been entirely free from symptoms 
for the past three weeks and she continued to be 
free during the summer. 

Case 2. — H. S. M., a woman, aged 29, has had 
hay-fever for five years, from August 15 to the 
first frost. The symptoms are sneezing, tickling 
in the throat and running of the nose, alternat- 
ing with stuffing up of the nose. She was first 
seen in June, 1918, and her symptoms had al- 
ready begun this year, much earlier than usual. 

She was treated with gradually increasing 
amounts of an autogenous vaccine made from 
her nasal secretion, from June 21 to August 14 ; 
the first treatment was 300 million streptococci. 
In the winter following this treatment, she re- 
ported that she had had only six bad days of 
hay-fever during the whole summer ; she claimed 
that she had been markedly free from hay-fever. 

The patient returned the following year, in 
May, 1919, and reported that her sneezing and 
running of the nose had just begun again. She 
was treated again with a new autogenous vaccine 
in a similar manner as was done the preceding 
year. During the first six weeks of treatment, 
she had occasional attacks of hay-fever, but not 
as bad as usual, during the remainder of the 
summer she was practically free from hay-fever. 

Case 3. — E. L. T., a woman, aged 30, has had 
hay-fever for four years, from August to the 
first frost. Her hay-fever is worse at night and 
prevents sleep. Her present attack began August 
26. She was not sensitive to pollens. 
[287] 



HAY-FEVER 

She was treated from September 1 to Octo- 
ber 6, inclusive, with an autogenous nasal secre- 
tion vaccine consisting of Staphylococcus pyo- 
genes aureus in gradually increasing amounts, 
beginning with 300 million bacteria ; during the 
season, she was given treatment with vaccines. 
Following the first treatment, she was a little 
better, and following each succeeding treatment 
she was free from symptoms for four days but 
had considerable hay-fever the two days preced- 
ing each treatment. 

These three patients would seem to prove that 
there are cases of seasonal hay-fever not caused 
by pollens but caused by bacteria and that treat- 
ment with autogenous vaccines made from their 
nasal secretions is often very effective. It is 
noted that in these non-sensitive pollen cases of 
hay-fever there was an absence of eye symptoms, 
as noted in a previous paper." 

Hay-Fever Caused by Olfactory Irritants or 
Pseudo-Hay -Fever. — Goodale" called attention 
to the fact that during pollen seasons certain 
individuals who are sensitive to and have ha}^- 
f ever from pollens also have vasomotor symptoms 
ranging from sneezing to asthmatic attacks due 
to the fragrance of certain heavily scented flow- 
ers that have no pollen or to which pollen the 

"Walker, I. C: Frequent Causes and the Treatment 
of Perennial Hay-Fever, J. A. M. A. 75: 782 (Sept. 18) 
1920. 

" Goodale, J. L. : The Present Status of Immuniza- 
tion in Hay-Fever. Boston M. & S. J. 179:293, 1918. 
[288] 



FOEMS OF TEEATMENT 

individual is not sensitive. He considers that the 
symptoms are reflex and that the path of trans- 
mission is along the olfactory nerve. The flowers 
most commonly responsible are lilies, hyacinths, 
sweet peas, lilacs, honeysuckle and peonies. 

I classify the causes of symptoms as mechani- 
cal, chemical, odorific and thermal. Among 
the mechanical causes any kind of dust is the 
most frequent cause, more especially sweeping 
dust and hay dust ; fine powder, such as talcum 
and the like, is also a frequent cause. Among 
the chemical irritants, soap powder, lye and 
ammoniacal fumes are very frequent causes. 
Among the odorific irritants, heavily scented 
perfumes, face powders, musty air and stable 
odors are frequent causes. Thermal irritants 
concern sudden changes of temperature, as in 
going from warm air to extreme cold, from 
moist air to very dry air, and exposure to drafts ; 
a very frequent history is that of a paroxysm 
of sneezing with or without running of the 
nose on retiring and arising. The mechanism 
seems to be a reflex due to the sudden exposure 
of the warm and protected skin of the body to 
cold air, as in getting out of bed and in undress- 
ing, during which acts the warm body surface 
is suddenly and momentarily exposed to cool air ; 
in other words, there is a mild chilling of the 
body surface." The same mechanism holds for 
many who take cold easily. Appropriate pollen 

"Mudd, S., and Grant, S. B.: Eeactions to Chilling 
of the Body Surface, J. M. Eesearch 40:53, 1919. 
[289] 





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[290] 



FOEMS OF TEEATMENT 

treatment for those who are sensitive usually; re- 
lieves these symptoms. 

SUMMABY 

The methods used by me in testing and treat- 
ing seasonal hay-fever and the seasons of polli- 
nation of the causative pollens are described 
in detail. Eight tables are then presented to 
illustrate the benefits obtained by preseasonal 
pollen treatment. Table 3 shows the unsatis- 
factory results obtained by giving less than 
three doses of the 1 : 500 dilution of the pollen 
extract, and the other seven tables show the 
good results obtained when more than three 
doses of the 1 : 500 dilution, or preferably 
one or more treatments with the 1 : 100 dilu- 
tion of the pollen extract are given. Tables 
1 and 2 deal with a single season's treat- 
ment, and Tables 4 to 8 inclusive, deal with 
two or more successive seasons' treatment. 
In general, the greater the amount of treatment 
given, the iDCtter the symptomatic results and the 
greater is the reduction in the positiveness of the 
skin test. Table 13 is a composite of Tables 1 
to 8 inclusive, with the exception of Table 3 
which concerns insufficient treatment. It shows 
the results obtained from preseasonal treatment 
with ragweed pollen and with the grass pollens 
for each year and the results for all four years. 

The percentage of results varies somewhat 
for different years; this is due, in great part, 
to variation in treatment. The average results 
[291] 



HAY-FEVEE 

for all four years following preseasonal ragweed 
treatment show that nearly 50 per cent, of the 
patients had little or no symptoms, and a third 
of the others were 75 per cent, benefited ; whereas 
in only 4.5 per cent, of all of the cases was there 
failure from treatment. In some of the in- 
dividual years, treatment showed much better 
results than this. The average results of treat- 
ment with the grass pollen group of cases shows 
that 60 per cent, of the patients had little or 
no symptoms, and 21.8 per cent, were 75 per 
cent, benefited, whereas 4 per cent, were not 
benefited. In some of the individual years, treat- 
ment gave much better results than in other 
years, and this variation was due to varying 
treatment. Unless patients return for future 
treatment, it is very difficult to get in touch with 
them in order to find out the permanency of re- 
lief from treatment. In four cases, however, it 
has been possible to learn that more or less 
permanency of benefit follows sufficient presea- 
sonal treatment. Case 11, treated in 1917, was 
also free from symptoms in 1918 and 1919 
without any treatment, but in 1920 this patient 
had severe symptoms. Case 1 was free from 
symptoms following treatment but has not been 
heard from since. Case 70 was free from symp- 
toms following treatment in 1919, and was also 
free from sjonptoms in 1920, without treatment. 
Case 312, free from symptoms in 1918 and 1919 
following treatment both years, had no symp- 
toms in 1920 without treatment. 

Tables 9 and 10 deal with during-the-season 
[292] 



FOEMS OF TEEATMENT 

pollen treatment, and the general conclusion is 
that during-the-season pollen treatment with the 
grasses is worth doing but is not as satisfactory 
as the preseasonal treatment, and that during- 
the-season treatment with ragweed pollen is very 
unsatisfactory. Treatment for the early type of 
hay-fever seems to yield better results than 
treatment for the late type. This is probably 
due to the fact that there are several causes for 
the early type of hay-fever such as June grass, 
rose and timothy pollen all of which pollinate at 
different times and each over a short interval 
and it is usually only one of these pollens that 
cause symptoms. Therefore, the actual cause of 
early hay-fever is present a short time, whereas 
ragweed which is practically alv/ays the only 
cause of late hay-fever pollinates as long a time 
as all of the early pollens together, and a much 
longer time than any one of the early pollens. 

Table 11 presents pollen sensitive patients 
who were treated with bacterial vaccines, and 
there is evidence that bacteria may, in some pol- 
len sensitive cases, play a part in the cause of 
hay-fever symptoms. With those patients who 
are not sufficiently benefited by supposedly satis- 
factory preseasonal pollen treatment, treatment 
with autogenous nasal vaccines is indicated dur- 
ing the pollen season. 

Table 12 presents eases treated with ragweed 
pollen preceding and during the season. In 
the case of patients not much benefited by satis- 
factory preseasonal pollen treatment, small doses 
of the pollen protein given during the season 

[293] 



HAY-FEVEE 

may produce benefit. In the case of those pa- 
tients who present themselves too late for suffi- 
cient preseasonal treatment, gradually increas- 
ing amounts of the pollen protein may be given 
throughout the hay-fever season. The results 
from this kind of treatment seem to be better 
than those from during-the-season treatment 
alone with either pollens or bacteria but not 
nearly as satisfactory as the result obtained 
from preseasonal pollen treatment that is begun 
early enough to permit of its discontinuance 
before the season of pollination. 

Since close contact with pollens that are 
closely related to the causative pollen, the eating 
of fruits, and certain olfactory irritants may all 
complicate the cause and the treatment of hay- 
fever, it is not remarkable that hay-fever treat- 
ment does not always afford entire protection. 

Other causes of seasonal hay-fever that must 
be considered are tree pollens, animal emanation 
and bacteria. 

CONCLUSIONS 

Satisfactory preseasonal pollen treatment 
yields excellent results in seasonal hay-fever. By 
satisfactory treatment is meant five or six treat- 
ments with a 1 : 500 dilution of the pollen ex- 
tract, or, better still, two or three treatments 
with a 1 : 100 dilution of the pollen extract. 

When preseasonal pollen treatment fails, 
sometimes benefit results from during-the-season 
treatment with pollens and sometimes from dur- 
ing-the-season treatment with an autogenous 

[294] 



FOEMS OF TREATMENT 

nasal secretion vaccine. During-the-season 
treatment with pollens without preseasonal treat- 
ment is not very satisfactory altho such treat- 
ment for the early type of hay-fever is worth 
doing provided for some reason or other it is 
not possible to give preseasonal treatment. 

Treatment that of necessity must begin late 
preseasonally may be continued on through the 
pollen season with better results than those ob- 
tained by during-the-season treatment alone, but 
with much less beneficial results than those ob- 
tained by beginning preseasonal treatment early 
enough to permit of its discontinuance before 
the season of pollination begins. 

Altho in the New England States the pol- 
len of ragweed (dwarf variety) is practically 
always the cause of late hay-fever (August and 
September), and the pollen of timothy grass is 
the cause of probably 90 per cent, of the early 
hay-fever (June and July), in other localities 
other pollens may play a great part in the cause 
of either type of hay-fever. For this reason 
it is essential that other observers publish their 
tests, results and treatment in detail in order 
to learn the causative pollens and proper treat- 
ment in various localities. 

In the New England States the pollen of 
rose and redtop grass occasionally cause early 
hay-fever, and treatment occasionally has to be 
given with these. The pollen of June grass is 
a more or less common cause of early hay-fever 
but when the season of its pollination is very 
early, unless the treatment is begun very early, 
[295] 



HAY-FEVER 

too little treatment can be given with it to 
be of benefit, and when its pollination is very- 
late, sufficient treatment with timothy pollen has 
been given to protect against June grass pollen 
exposure. 

Treatment with a combination of timothy and 
June grass pollens was not successful in my 
hands because of insufficient treatment with 
both pollens; the addition of June grass pollen 
retarded the amount of treatment that otherwise 
would have been given with timothy alone. An- 
other illustration of the undesirability of mixed 
pollen treatment is noted with those patients who 
have both the early and the late types of hay- 
fever. In these cases, during the month of May 
and part of June, large amounts of timothy pol- 
len extract should be given together with small 
amounts of ragweed pollen extract, and the re- 
sult in these cases is rather poor because there 
is a tendency to restrict the timothy treatment 
for fear of producing anaphylaxis from the com- 
bination of two pollens to which the patient is 
sensitive. In other words, treatment with a com- 
bination of pollens either diminishes the amount 
of treatment that is required with one or all of 
them or pushing the treatment with the combina- 
tion leads to the danger of anaphylaxis. For 
either or both of these reasons, I see no benefit 
to be derived from mixed pollen therapy. As 
regards the early type of hay-fever, I consider it 
best to treat preseasonally with timothy or the 
chief causative pollen and, if necessary to treat 
during the season with June grass pollen. 
[296] 



FOEMS OF TEEATMENT 

Since intimate exposure to other pollens which 
may be attributing causes of hay-fever, the eat- 
ing of fruits during the hay-fever season, the 
possibility that bacteria play a part in the cause 
of hay-fever and the exposure to olfactory irri- 
tants may all aggravate the symptoms of hay- 
fever, it is not remarkable that hay-fever treat- 
ment is not perfect." 

16. Selfridge," Koessler** and Scheppegrell" have pub- 
lished the prevailing pollens in their respective localities, 
namely, California, Illinois and the Southern States and 
they designated those pollens that seem to be the chief 
causes of hay-fever in these localities. It is desirable that 
others in various localities do likewise. 

17. Selfridge, G. : Spasmodic Yasomotor Disturbances 
of the Respiratory Tract, with Special Reference to Hay- 
Fever, California State J. M. 16: 164, 1918. 

18. Koessler, K. K. : The Specific Treatment of Hay- 
Fever (Pollen Disease), Billings-Forchheimer Therapeusis 
of Internal Diseases, 5: New York, D. Appleton & Co. 

19. Scheppegrell, W.: Hay-Fever in the Southern 
States, Southern M. J. 9:614, 1916. 



[297] 



HAY-FEVER 



7. The Pbesent-Day Conception op 
Hay-Fever* 

By H. K. Detweiler, m.d. 

Clinician in Medicine, University of Toronto and 
Toronto General Hospital 

It is hardly necessary to define the term *' hay- 
fever" since the disease is so common that every 
one is quite familiar with the symptom-complex 
with which this term is associated. Nevertheless^ 
there are so many other conditions in which this 
group of symptoms is predominant that it may 
be wise to restrict the term to those cases in 
which the etiological factor is the pollen of one 
or more plants. Barker^ defines the disease as 
*'a more or less severe inflammation of the 
mucous membranes of the nose, throat and 
bronchi, occurring in susceptible persons in the 
spring or in the autumn and caused by the in- 
halation of pollens of certain plants." 

Historical. — It was not until 1873 that Black- 
ley,' as a result of careful researches, called 
attention to the periodicity of the disease, and 
definitely established the relationship existing 

*From the Department of Medicine, University of 
Toronto. Courtesy of the Canadian Medical Association 
Journal. Eead before the Hastings County Medical 
Society, October 13th, 1920. 

^Barker. — ''Monographic Medicine,'' vol. 2, 1916. 
'Blackley.— :Braw7i Med. Journ., 1898, 1, 867. 
[298] 



FOEMS OF TEEATMENT 

between the attacks and the presence of certain 
pollens in the air at these periods. In 1905 Dun- 
bar' confirmed Blackley's observations and ex- 
tended them. He introduced the method of 
treatment by the use of pollen, but believed that 
his extract of pollen was a true toxin which, 
upon inoculation into horses would call forth 
the production of antitoxin. This immune 
serum he called Pollantin, and used it in an at- 
tempt to produce a passive immunity in the 
patient. The results have not been sufficiently 
favorable to warrant the adoption of the method. 

Since then, many investigators have devoted 
long and careful study to this disease and active 
prophylactic immunization by means of pollen 
extracts has definitely been established as the 
best method of treatment at our command. 

Protein Sensitization. — In individuals who 
manifest a hypersusceptibility to a protein, the 
administration of such protein, either hypo- 
dermically or intravenously, gives rise to a more 
or less violent reaction which may manifest 
itself by symptoms of profound shock, an attack 
of asthma, or the symptom-complex of hay-fever. 
Sometimes these symptoms may be brought on 
by the mere ingestion of the offending protein, 
or by its absorption through the mucous mem- 
branes of the nasal passages and bronchi. It 
has long been held by many observers that these 
phenomena are of the nature of anaphylaxis. 
More recently, observations on drug hypersua- 

" Dunbar. — Berliner Tclin. Woch., 1905, 11, 635. 
[299] 



HAY-FEVER 

ceptibility in which there is no protein element, 
have cast some doubt upon the adequacy of this 
explanation. The writer had occasion to test a pa- 
tient (a physician) in Walker's clinic, complain- 
ing of asthma and eczema, in whom the attacks 
were brought on while administering arsphena- 
mine. Cutaneous tests with a solution of this 
drug yielded a result comparable in every way 
to those obtained in cases sensitive to proteins. 
Quinin has also been found to produce a similar 
result in suitable cases. Coca* urges that the 
term anaphylaxis be restricted to instances where 
the result is shown to be due to an antigen- 
antibody reaction, and claims that a true case 
of anaphylaxis in a human being has never yet 
been reported. He suggests the term "allergy" 
to cover all instances in which there is no proof 
of an antigen-antibody reaction. The term is 
by no means a new one but his suggested restric- 
tion of its use is new. A full discussion of this 
question is not wdthin the scope of the present 
paper and it will be necessary to content our- 
selves with the statement that while the major- 
ity of investigators still favor the anaphylaxis 
theory to explain the phenomena of hay-fever 
and bronchial asthma, there are serious objec- 
tions which will have to be satisfactorily dealt 
with before the question is finally settled. 

The table on following page taken from 
Walker,' is an excellent means of visualizing the 

*Coca. — ^'Tice's Practice of Medicine," vol. 1, W. F. 
Prior Co., 1920. 

''Walker.— ** Oxford Medicine,'' 1920, vol. 2. 
[300] 






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[301] 



HAY-FEVEE 

various causes of hay-fever and their relation- 
ships to each other. The non-sensitive cases are 
nearly always due to bacterial infection and 
should not properly be called hay-fever. These 
cases are characterized by a more tenacious type 
of secretion rather than the typical thin, watery 
discharge of true hay-fever. Moreover, the eyes 
are less commonly affected and the whole picture 
more closely resembles an ordinary coryza, or 
common "cold." It is not difficult to conceive 
of such a phenomenon occurring during certain 
seasons of the yeax, — particularly in the autumn 
and winter. It may also be present more or less 
continuously throughout the year. Oases of so- 
called spasmodic vasomotor rhinitis occurring 
as a result of the presence of abnormalities of 
the nasal passages and sinuses are comparatively 
uncommon, and as Barker suggests, "the physi- 
cian should protect the hay-fever patient from 
the useless nasal operations of over-zealous surgi- 
cal enthusiasts!" There are, nevertheless, cer- 
tain cases presenting symptoms simulating non- 
seasonal hay-fever, which are relieved after the 
removal of polyps or other gross abnormalities. 

Seasonal Sensitive Cases. — During April and 
May the various trees pollinate, — each variety 
requiring approximately two weeks or less to 
complete the process. Therefore, if an individual 
is sensitive to willow, for example, the attack 
will last only a very short time and specific 
treatment will not be worth while. If, however, 
the patient is sensitive to a number of pollens 
which are shed at different times, the attack 

[302] 



FOEMS OF TEEATMENT 

may last for a considerable period, and prophy^ 
lactic inoculation may be advisable. Such cases 
are comparatively rare. 

The next pollen season begins in early June 
and lasts until the latter part of July. During 
this time the grasses shed their pollens. It is 
true that other pollens are also met with in this 
period, for example, that of the rose and of the 
daisy, but these seldom cause hay-fever, in 
spite of the popular belief as evidenced by the 
familiar terms "rose cold" or "rose fever." 
The chief cause of the disease during this sea- 
son is the pollen of timothy, with that of June 
grass and redtop ranking next. The term 
' ' hay-fever ' ' in its narrow sense should really be 
restricted to the cases occurring during this 
period, — since it is only at this time that the 
pollens of grasses used in making hay are the 
causative agents. 

The third and most important pollen season 
begins in this country about the twentieth of 
August, — often a few days earlier. It lasts 
until the first heavy frost, which usually 
occurs the first week in October. During this 
season the chief offender is the pollen of rag- 
weed. Occasionally goldenrod and daisy are 
found to be causal agents. It is true that very 
often in testing the patients for sensitiveness 
all three pollens are found to yield a positive 
result, but almost invariably that of ragweed 
causes by far the strongest reaction, with golden- 
rod a poor second and daisy faintly positive. 
Since these plants are related, such findings 

[303] 



HAY-FEVER 

are believed by most competent observers to be 
an example of ^' group reaction," so familiar 
to bacteriologists. If this interpretation is the 
correct one, the reactions caused by goldenrod 
and daisy are in the majority of instances to be 
disregarded. 

There are a certain number of sensitive cases 
in which pollens are shown not to be the cause 
even tho the disease occurs in certain sea- 
sons only. Such individuals will react to one 
or more of the proteins of foods, animal dan- 
druff, hair or feathers, or bacteria. "With re- 
spect to the last mentioned, attention should be 
drawn to the point made by Walker, that bac- 
teria may cause symptoms simulating hay-fever 
in two ways: (1) by a sensitiveness to the bac- 
terial proteins; (2) by virtue of the infection 
by the micro-organism. The latter element was 
considered earlier in this paper, in referring to 
the non-sensitive cases. In all these instances, 
the seasonal incidence would have to be ac- 
counted for by a seasonal exposure to the par- 
ticular protein concerned. This is readily un- 
derstood in the case of certain foods and animals, 
and in the case of bacteria it would seem that 
infection somewhere in the body at stated sea- 
sons of the year would have to precede the 
appearance of hay-fever symptoms due to a 
susceptibility to the protein of the organism 
present. An example of a seasonal hay-fever 
caused by a food protein is described in the para- 
graphs discussing methods of diagnosis. 

Where the proteins of animal hair, foods, and 
[304] 



FOEMS OF TEEATMENT 

bacteria are the causal agents of hay-fever symp- 
toms, the disease is usually non-seasonal in type. 
The total number of cases causes by these pro- 
teins is comparatively small, as for some un- 
known reason the symptoms produced by sus- 
ceptibility to the substances are nearly always 
asthmatic in nature. Hay-fever symptoms are 
fairly frequently found, however, in persons 
riding horses or fondling pets, such as cats and 
dogs. Zinsser^ cites the case of a laboratory 
attendant who was always seized with violent 
sneezing attacks, with running of the eyes and 
nose, whenever he handled guinea-pigs in the 
course of his work. 

Symptoms. — In those who are affected with 
hay-fever, the disease makes its appearance 
every year at approximately the same time. It 
begins as an irritation of the nasal and con- 
junctival mucous membranes, with itching and 
sneezing as prominent symptoms. In a very 
short time, the eyes begin to water profusely, 
and there is a thin watery discharge from the 
nose. A cough is sometimes present, and in 
certain cases, asthma develops sooner or later in 
the season. There is often marked mental de- 
pression, with inability to concentrate the mind. 
General malaise, headaches and insomnia are 
sometimes marked symptoms, and in severe cases 
the disease is of the most distressing character. 
During the attack the nasal and pharyngeal 
mucous membrane is rendered so irritable that 

"Zinsser. — *' Infection and Eesistance," 1914. 
[305] 



HAY-FEVER 

dust or smoke will serve to aggravate the con- 
dition produced by the protein to which the 
patient is sensitive. The symptoms persist until 
the end of the period of pollination of the par- 
ticular plant or plants concerned. As pointed 
out before, the season for the trees is quite short, 
but the grasses begin early in June and last until 
late in July. The ragweed season begins about 
the middle of August and ends with the first 
heavy frost. Not a few patients are sensitive 
to both grass and ragweed. In such cases there 
is little respite from June to October. 

Methods of Diagnosis. — The methods employed 
in the accurate diagnosis of the disease rest on 
the basis of the observations of Dunbar^ and 
others, that in sensitive subjects, the mere plac- 
ing of the offending pollen upon the slightly 
abraded skin will cause a local reaction as evi- 
denced by the appearance of the wheal and a 
surrounding area of erythema. The actual tech- 
nic as now employed is as follows: A series 
of very slight scratches with a sharp scalpel are 
made on the ventral surface of the forearm. 
These scratches or cuts should not be deep 
enough to draw blood, and not longer than an 
eighth of an inch. They should be placed about 
one inch apart. The one nearest the elbow is 
left untouched as a control. A small amount of 
a suspected pollen is placed on the first abrasion, 
and dissolved by adding a drop of N-lOO sodium 

' Dunbar. — Zeitschr. f. Immunitatsforsch, vol. 7, 1907 ; 
Deutsche med. Woch., vol. 37, 1911, page 578. 
[306] 



FOEMS OF TEEATMENT 

hydroxid. The next scratch is treated similarly 
^vith another pollen, and so on down the arm 
■until all the pollens which might reasonably be 
expected to be capable of causing symptoms at 
that season of the year, have been applied. In 
the average case one notices, within a few 
minntes, a red areola appearing around the abra- 
sions treated with the offending pollens. In 
the center of this areola, about the scratch, a 
wheal will be observed which gradually increases 
in size. The test is considered complete after 
thirty minutes, but it is usually unnecessary to 
allow the solutions to act longer than fifteen 
minutes. 

Some observers prefer to inject solutions of 
the pollen protein intradermally instead of per- 
forming the cutaneous test as outlined above, 
but there are valid objections to this method. 
Chief among these is the fact that it is often 
difficult to differentiate a slight positive reac- 
tion from a negative one, as the injection of any 
solution into the skin necessarily gives rise to 
a wheal of certain proportions, due merely to 
the bulk of the fluid. Other objections will be 
considered in taking up the technique of esti- 
mating dosage in treatment. 

While the diagnosis of hay-fever may usually 
be made from the symptoms complained of by 
the patient, there is likely to be, nevertheless, 
quite an appreciable percentage of error if more 
accurate methods are not employed. Cases com- 
plaining of symptoms simulating seasonal hay- 
fever may present themselves, and the diagnosis 
U307] 



HAY-FEVEE 

seem to be so obvious that sensitization tests 
appear superfluous. Such a case was tested by 
the writer in the clinic of Dr. I. Chandler 
Walker at the Peter Bent Brigham Hospital in 
Boston, and is cited by the latter in his recent 
paper/ This case, a housewife, complained of 
sneezing, watery secretions from eyes and nose, 
and general symptoms of coryza during the 
summer only. The history of her case did not 
differ materially from that usually obtained from 
patients sensitive to both the grasses and rag- 
weed. Tests with the pollens, however, were en- 
tirely negative, and in subsequent routine tests 
with animal and food proteins, she was found to 
be sensitive to the proteins of wheat. We were 
at a loss to explain the periodicity of her trou- 
ble on this basis until she volunteered the in- 
formation that every summer she takes a posi- 
tion as baker in a summer hotel. Apparently 
the ingestion throughout the winter of wheat 
bread and other foods containing wheat flour is 
not sufficient to produce symptoms, but that 
added to the amount of wheat protein breathed 
into the nostrils during the mixing of pastry, 
etc., pushed her over the threshold. 

Treatment. Specific protein treatment. — The 
most successful method of treating hay-fever 
has proven to be the prophylactic inoculation 
of the patient with the specific protein causing 
the disease. Solutions of the pollen protein are 

* Walker. — Jour. Am. Med. Assoc, September 18th, 
1920. 

[308] 



FOEMS OF TEEATMENT 

made, grading the dilutions of the protein from 
1-500 to 1-20,000 or higher. A preliminary test 
with the various dilutions is made by placing a 
drop of the solution on a scratch on the skin, 
having as many scratches as there are dilutions 
of the pollen. The initial dose (hypodermic) 
of the pollen will be 1 c.c, of the dilution next 
higher than the last one giving a positive skin 
test. Suppose 1-5000 gives a faintly positive 
test; the schedule of treatments would then be 
1-10000 give 01 c.c, 1-5000 give 01 c.c, 0-2 
c.c, 01 c.c, 1-1000 give 01 cc, 0-2 cc, 1-500 
give 01 c.c, 2 c.c, 0-3 cc, 0-4 cc, 1-100 give 
0-1 c.c. and 0-2 cc (Walker). 

Some workers use the intradermal injection 
of the various dilutions to determine both the 
diagnosis and the degree of sensitiveness. Not 
only does this method produce a slight wheal 
from the injection itself, but even comparatively 
inert substances may produce effects which are 
only with difficulty differentiated from a slightly 
positive test. For this reason this method is 
not to be depended upon to determine the initial 
dose to be administered in the process of de- 
sensitization, whereas the cutaneous method 
lends itself admirably for this purpose. 

The treatments should be given one week 
apart, and should be completed by the time the 
season begins. Therefore the course of inocula- 
tions should begin three months before the at- 
tack is expected. Such a course of treatment 
should protect the patient for that season, and 

[309] 



HAY-FEVER 

the schedule will have to be repeated each year 
— at least for a few years. 

In cases sensitive to animal hair, a similar 
routine is carried out over quite a long period 
until the skin test shows the patient to be no 
longer sensitive to strong solutions of the pro- 
tein. The most satisfactory method of treating 
food cases is simply to omit such food from the 
diet. Abstinence for a year or more often re- 
sults in an automatic desensitization of the pa- 
tient, who may then add the food to the regu- 
lar diet without ill effect. 

Climate. — For those who are able to do so, a 
sojourn during the hay-fever season in one of 
the resorts which are free from the offending 
pollen will usually prove efficacious, Muskoka 
and the Georgian Bay are free from ragweed, 
altho some goldenrod is found. Generally, 
speaking, however, the autumn cases do well in 
these localities. 



[310] 



FORMS OF TREATMENT 



8. Frequent Causes and the Treatment op 
Perennial Hay-Fever* 

By Chandler Walker, m.d. 

BOSTON 

During the last five years while I was study- 
ing bronchial asthma, many patients who com- 
plained of having hay-fever throughout or at 
any time of the year presented themselves for 
study and treatment. All of the patients that 
are presented in this paper were either examined 
while under observation or had recently been 
examined by competent nose and throat spe- 
cialists in order to exclude pathologic conditions, 
growths and the like, that might be the cause of 
sjnnptoms. On some of the patients, repeated 
nasal operations had been performed; with 
others, no cause for operation had been found, 
but much local treatment had been given. 
Therefore it may be stated that most if not all 
of these patients had symptoms that were not 
benefited by the usual treatment employed by 
rhinologists. As will be shown in this paper, the 
cause of the symptoms in such cases may often 
be determined by cutaneous skin tests, and relief 

* From the medical clinic of the Peter Bent Brigham 
Hospital. Reprinted from The Journal of the American 
Medical Association, Sept. 18, 1920, Vol. 75, pp. 782- 
789. Copyright, 1920. American Medical Association, 
Chicago. 

[311] 



HAY-FEVER 

may often be obtained by consentient treatment. 

Altho it has been well known for years that 
certain persons have hay-fever from exposure 
to animals, only recently has the real causative 
agent been recognized and appropriate treat- 
ment instituted. For these reasons it seems 
worth while to give a few protocols illustrative 
of these cases. Likewise, since the ingestion of 
foods and the presence of bacteria in the nasal 
cavities, exclusive of a definite infectious proc- 
ess, have only recently been recognized as a 
possible cause of perennial hay-fever, a few pro- 
tocols illustrating these cases will be presented. 
The association of hay-fever symptoms through- 
out the year with true pollen or seasonal hay- 
fever and with olfactory irritants will be dis- 
cust. Finally, attention will be called to a 
group of cases in which there were eye symptoms 
alone as a result of eating certain foods. 

With those patients who have perennial hay- 
fever due to animal emanations, foods and pol- 
lens it is usually the protein in these substances 
that causes the symptoms ; in the case of the bac- 
teria it may be the protein or it may be the 
infectious element. In testing with the animal 
emanations or epidermal proteins, the protein 
and the peptone should be used separately ; with 
the cereal grains, the globulin fraction of the 
protein is most important ; with other foods and 
with pollens and bacteria the whole protein 
seems to suffice. Before treatment may be given 
to those who are sensitive to a protein, cutaneous 
skin tests should be made with different dilu- 
[312] 



FORMS OF TREATMENT 

lions of the offending protein, and treatment 
should be started with the strongest solution 
that fails to give even the slightest degree of 
reaction. 

Described briefly, the cutaneous skin test con- 
sists of inoculating a series of small cuts or 
scratches on the flexor surface of the forearm 
with the different proteins to be tested. A posi- 
tive reaction consists of a definite wheal, with 
or without an area of erythema, and the protein 
giving such a reaction is usually the cause of the 
symptoms and should always be considered as 
the cause until proved otherwise. 

PERENNIAL HAY-FEVER CAUSED BY HORSES 

I have successfully treated twenty patients 
who had hay-fever caused by emanations from 
horses. Many of the patients knew that ex- 
posure to horses caused their symptoms, and they 
desired to be treated so that they could be around 
them. Others were not aware of the cause of 
their symptoms until the cutaneous tests were 
made. Protocols of ten cases will be given in 
more or less detail. Protocols of the other ten 
cases will not be given because they closely re- 
semble those being presented, and they furnish 
nothing of additional interest. Two of the cases 
not presented are worthy of mention in that 
the patients were officers during the recent war, 
and as such they were required to use horses, 
which caused them to have violent hay-fever. 
After several inoculations, however, with the 
[313] 



HAY-FEVER 

offending protein these patients were able to be 
around horses ad libitum without any symptoms. 

Case 1. — L. K. B., a man, aged 31, had had 
hay-fever caused by horses all his life. The at- 
tacks lasted three or four days at a time, and 
they occurred throughout the year. He was a 
cashier in a country bank, and whenever, as very 
frequently it happened in the winter, a person 
who had been driving a horse shook or brushed 
his fur coat in the presence of the patient, an 
attack of sneezing, itching of the eyes and run- 
ning of the eyes and nose was precipitated by 
the horsehair and dandruff dislodged by the 
shaking of the fur coat. The patient also 
sneezed every morning on arising. 

Cutaneous tests were negative with the pro- 
teins of the common foods, pollens and feathers, 
but were positive with the hair of the cat, dog 
and horse. The patient was most sensitive to 
the protein of horsehair and dandruff; a dilu- 
tion of 1 : 100,000 gave a positive reaction. 

The patient was treated once a week with a 1 : 
1,000,000 solution of horse epidermal protein in 
gradually increasing amounts ; the first dose was 
0.1 c.c, and this was increased 0.05 c.c. each suc- 
ceeding week until 0.8 c.c. was given at one time. 
During this series of treatments the patient be- 
came free from his customary morning sneezing, 
and the shaking of fur coats laden with horse- 
hair and dandruff no longer caused symptoms; 
he was still, however, unable to ride behind a 
horse without having his usual symptoms. Treat- 
ment was continued with a stronger solution of 
[314] 



FOEMS OF TEEATMENT 

the protein of horsehair and dandruff, namely, 1 : 
100,000, in the same dosage as outlined above, 
and before treatment with this solution was com- 
pleted the patient was able to ride behind horses 
without symptoms. 

Case 2. — C. M., a woman, aged 18, for the 
last four years had been subject to attacks of 
sneezing, itching of the eyes and running of the 
eyes and nose and difficulty in breathing through 
the nose when near horses; these attacks would 
continue for two or three hours following ex- 
posure. She had frequently been awakened by 
such attacks in the summer time when a horse 
had passed by the open window of her sleeping 
room. During one summer which was spent on 
an island where there were no animals she was 
free from symptoms, but on returning to the 
city in the fall she had an attack which lasted 
two weeks. She was subject to frequent head 
colds. 

Cutaneous tests were negative with the pro- 
tein of the common foods, pollens and animal 
emanations, with the exception that the protein 
of horsehair and dandruff was positive in a dilu- 
tion of 1 : 1,000. 

The patient was given a series of five treat- 
ments at weekly intervals with horsehair dan- 
druff protein in a dilution of 1 : 10,000, begin- 
ning with 0.2 c.c. and increasing the dose 0.1 
c.c. each succeeding week. Following these 
treatments she was able to ride horseback with- 
out symptoms, and had very little trouble when 
riding behind a horse. The patient was then 
[315] 



HAY-FEVER 

given a series of twelve treatments with the horse 
epidermal protein in a 1:1,000 dilution; the 
first dose was 0.1 c.c, the maximum or last dose 
was 0.8 c.c, and the increase each time was 0.05 
c.c. The larger number of doses in this series 
was made necessary because several times the 
patient had a very sore arm following some of 
the increased amounts, thus necessitating a repe- 
tition of the preceding dose before an increase 
was deemed advisable. During this series of 
treatments the patient was able to ride behind 
horses without any symptoms at all, and she had 
been free from her usual frequent head colds 
during the last winter. Treatment was then 
given with a 1 : 100 dilution of the horse epi- 
dermal protein for eight weeks according to the 
same schedule as outlined above for the 1 : 1,000 
dilution. By this time the cutaneous tests were 
negative with the 1 : 100 solution, and the con- 
centrated powder of the hair and dandruff pro- 
tein gave only a very doubtful reaction, which 
consisted of a small area of erythema but no 
wheal. After this the patient was lost sight of 
for more than two years, when a letter was re- 
ceived from her stating that she was still free 
from symptoms and was able to be about horses 
as much as she desired. 

Case 3.— W. G. T., a man, aged 29, had had 
hay-fever symptoms since childhood when he was 
near horses and when he went into a horse 
stable; exposure to cold air also provoked hay- 
fever symptoms. In addition, he had had con- 
tinuous hay-fever from the latter part of August 
r.316] 



FOEMS OF TEEATMENT 

to October during the last summer, but never 
previously. 

Cutaneous tests were positive with the protein 
of ragweed and goldenrod pollens and with the 
proteins of horsehair and dandruff in a dilution 
of 1 : 1,000. 

Treatment was given with a series of inocula- 
tions of the 1 : 10,000 dilution of the epidermal 
horse protein and then with a series of the 
1 : 1,000 dilution as already indicated in Case 
2. The patient no longer had symptoms from 
exposure to horses, nor did exposure to cold air 
provoke symptoms. The following spring he 
was successfully inoculated against ragweed pol- 
len hay-fever. 

Case 4. — M. W. J., a woman, aged 23, had had 
hives and sneezing and running of the eyes and 
nose since infancy when near horses. The hay- 
fever symptoms occurred at all times of the 
year and were also caused by dust. 

Cutaneous tests were negative with the pro- 
teins of foods, pollens, cat hair and feathers. 
Dog hair protein gave a positive reaction in a 
dilution of 1 : 100, and both proteins of horse- 
hair and dandruff were positive in a dilution of 
1 : 100,000. 

The patient was given six treatments at 
weekly intervals with a 1 : 1,000,000 dilution of 
horse epidermal protein; the first dose was 0.2 
c.c, and this was gradually increased each week 
until the sixth dose was 0.6 c.c. Following this 
series of treatments, the patient experienced 
much less trouble when around horses. Treat- 
[317] 



HAY-FEVER 

ment was continued for nine weeks with a 
1 : 100,000 dilution of the protein, and then for 
nine weeks with a 1 : 10,000 dilution of the pro- 
tein; with each dilution the first dose was 0.2 
C.C., and each succeeding week the amount was 
increased 0.05 c.c. By this time the patient had 
no symptoms whatsoever from horses, and even 
dust no longer caused symptoms. Seven months 
have now elapsed since the last series of inocu- 
lations, and the patient is still free from 
symptoms. 

Case 5. — C. S., a girl, aged 10, had had hay- 
fever when near horses for eight years. She now 
desired to own and take care of a pony. 

Cutaneous tests were positive with the pollens 
of timothy grass and ragweed, and with both 
horse epidermal proteins in a dilution of 
1 : 10,000. 

Treatment was given with a 1 : 100,000 dilu- 
tion of horsehair and dandruff protein six times 
at weekly intervals; the doses given were 0.1, 
0.2, 0.3, 0.5, 0.7 and 0.9 c.c. She was then given 
0.2, 0.3 and 0.4 c.c. of a 1:10,000 dilution. 
Following this treatment she was able to ride 
behind horses with no sneezing or running of the 
eyes and nose, altho her eyes would itch and 
get red. Two more treatments were given with 
this dilution ; then a 1 : 1,000 dilution of the 
proteins was given for seven weeks, and finally 
five treatments with a 1 : 100 solution were given. 
By this time cutaneous tests were negative with 
the epidermal peptone and only slightly posi- 
tive with the epidermal protein. Treatment 
[318] 



FORMS OF TREATMENT 

was then begun with the pollens. All of this 
treatment was given during the winter of 1917. 
It has now been three years since treatment was 
discontinued, and the patient has had no symp- 
toms, altho she has owned and taken all the 
care of a pony and has been around horses 
freely. 

Case 6. — P. H., a girl, aged 8, had had sneez- 
ing, running of the eyes and nose and itching 
of the eyes for several years when riding behind 
horses. She had had asthmatic attacks since 
infancy. She had to ride behind a horse to and 
from school. 

Cutaneous tests were positive, along with 
other proteins, with horse epidermal proteins in 
a 1 : 10,000 dilution. 

Treatment was given with a 1 : 100,000 dilu- 
tion of both horse epidermal proteins until she 
was able to ride behind horses; altogether, ten 
treatments were given. After this, horse epi- 
dermal protein treatment was discontinued 
because, since she was now able to ride behind 
horses to and from school, it was considered 
best to treat the asthmatic condition which was 
due to other proteins. 

Case 7. — H. B., a man, aged 40, declared that 
he was so sensitive to horses that he would have 
hay-fever, followed in a few minutes by asthma, 
whenever he went on a congested street where 
there were horses, or whenever he even went 
into a harness-repairing shop. 

Cutaneous tests were positive with the horse- 
hair and dandruff proteins; the peptone was 
[319] 



HAY-FEVER 

positive in a 1 : 10,000 dilution, and the protein 
was positive in a 1 : 1,000,000 dilution. 

Treatment was given nine times with a 1 : 10,- 
000,000 dilution of the horsehair and dandruif 
protein at weekly intervals in these doses: 0.1, 
0.15, 0.2, 0.25, 0.3, 0.4, 0.5, 0.6 and 0.7 c.c. The 
patient was now able to go into a harness-repair 
shop and to go near horses without symptoms. 
A similar series of treatments was then given 
with a 1 : 1,000,000 dilution of the protein, fol- 
lowing which circumstances caused an inter- 
ruption of treatment. 

Case 8. — E. G., a girl, aged 13, had had 
sneezing and running of the eyes and nose and 
itching of the eyes for the last year when riding 
behind horses and when on horseback. She de- 
sired treatment that she might ride horse-back. 
She also had hay-fever in August and Sep- 
tember. 

Cutaneous tests were positive with ragweed 
pollen and with the horse epidermal proteins in 
a dilution of 1 : 1,000. 

Treatment was begun with 0.2 c.c. of a 1 : 10,- 
000 dilution of both horse epidermal proteins. 
Three days later the patient rode horseback with 
others in an enclosed ring which was very dusty, 
with no nasal or eye symptoms. Treatment has 
continued with equal success. 

Case 9. — M. G., a woman, aged 21, had had 

hay-fever for ten years; she had a cold in the 

head all the time; her eyes and nose ran and 

she sneezed all through the year, and these 

[320] 



FORMS OF TREATMENT 

symptoms were worse when she was riding be- 
hind a horse. 

Cutaneous tests were positive only with the 
proteins of horsehair and dandruff, and with 
these in a 1 : 100 dilution. 

She was treated nine times with a 1 : 1,000 
dilution of the proteins and five times with a 
1 : 100 dilution. Following- this treatment she 
had no symptoms when riding behind horses, 
and in general she had much less trouble; still 
she was not free from symptoms when not near 
horses. An examination of her nose revealed 
polyps, hypertrophied middle turbinates, and a 
very large spur on the septum. Removal of the 
polyps and spur relieved her symptoms of hay- 
fever entirely. Therefore, altho treatment 
with the epidermal proteins relieved the hay- 
fever, which was caused by horsehair and dan- 
druff, it was necessary to remove .he polyps and 
the spur before complete relief was obtained. 

Case 10. — J. C. W., a woman, aged 44, had 
had hay-fever throughout the year for many 
years; her symptoms consisted of sneezing and 
running of the nose and at times stuffing up of 
the nose for two or three days at a time on an 
average of once a week. 

Cutaneous tests were positive with the pro- 
teins of horsehair and dandruff in a 1 : 10,000 
dilution, but were negative with food, pollen 
and other animal hair proteins. 

Treatment was given as outlined in previous 
cases with a 1 : 100,000 dilution of the horse 
epidermal proteins, and then a few treatments 
[321] 



HAY-FEVER 

were given with a 1 : 10,000 dilution, until the 
patient became free from symptoms. The 
patient then discontinued treatment for several 
months until slight symptoms returned; then 
more treatment was taken for a short time, and 
again freedom from symptoms resulted. After 
this the patient went three months without 
treatment, when slight symptoms again re- 
turned, and more treatment was taken, with the 
usual relief. 

The horse protein hay-fever protocols illus- 
trate several points which may well be em- 
phasized. In Cases 1, 2, 5 and 6 the treatment 
is given in detail in order to show that treat- 
ment should be begun with the strongest solu- 
tion of the protein that fails to give any reac- 
tion by the cutaneous test. Each week the 
amount of the inoculation is slowly and grad- 
ually increased until 0.8 c.c. is given as the last 
or maximum dose before the next stronger solu- 
tion is given. In Case 2, several doses had to be 
repeated because some of the amounts caused 
a sore arm, whereas all of the other patients took 
the usual schedule of dosage without ill effects. 
Case 5 illustrates the fact that, if sufficient 
treatment is given to render the cutaneous test 
negative with the concentrated powder of the 
protein, complete and permanent desenskization 
results since three years have elapsed since the 
last treatment with no return of symptoms, even 
tho the patient is constantly exposed to 
horses. Case 2 probably illustrates this point, 
since more than two years have elapsed with 
[322] 



FORMS OF TREATMENT 

equally good results. Case 3 shows that only a 
very few treatments are required to enable a 
horse-sensitive patient to ride horseback, and 
Case 6 shows that a few more additional treat- 
ments are required to permit the patient to ride 
behind a horse. Cases 3 and 4 show that it 
does not require many treatments to protect a 
patient from ordinary exposure to horses. Case 
10 shows that altho a few treatments will 
protect a patient for a few months, such protec- 
tion is not lasting, and more treatment is re- 
quired after a time. In other words, these 
protocols show that the longer the course of 
treatments, the longer and the more complete is 
the protection, and that sufficient treatment will 
probably protect indefinitely. 

Cases 1 and 7 illustrate the extreme sensi- 
tiveness of some persons to horsehair and dan- 
druff proteins, as demonstrated both by their his- 
tory and by their cutaneous tests. Sufficient 
horsehair and dandruff protein is carried in the 
air in congested parts of a city to cause symp- 
toms in patients that are so extremely sensitive 
to these proteins. The treatment of such pa- 
tients has to be started with a very dilute solu- 
tion of the protein, and great care must be exer- 
cised in order to avoid an overdose. In spite of 
these facts, if the cutaneous tests are carefully 
made, no ill effects result from proper treat- 
ment, and satisfactory results are obtained. 



[323] 



HAY-FEVER 



PERENNIAL. HAY-FEVER CAUSED BY CATS 

Cats probably do not cause hay-fever so fre- 
quently as do horses, since I have observed only 
six cases. Four of these patients were willing 
to dispense with their cats, and after doing so 
were free from symptoms. Two patients, how- 
ever, preferred treatment to dispensing with 
their pet ; protocols of these two cases follow. 

Case 11. — W. D., a boy, aged 12, once every 
month had had attacks of sneezing and running 
of the nose and eyes, followed by wheezing, 
shortness of breath and cough since 18 months 
of age. 

Cutaneous tests were positive with the epi- 
dermal protein of the horse, dog and cat, but 
the patient was most sensitive to the proteins of 
cat hair; cat hair peptone gave a positive reac- 
tion in a 1 : 10,000 dilution. 

Ten treatments were given at weekly intervals 
with cat hair peptone in a 1 : 100,000 dilution as 
follows: 0.1, 0.15, 0.2, 0.3, 0.4. 0.5, 0.6, 0.7, 0.8 
and 0.9 c.c. Following this a similar series of 
treatments was given with a 1 : 10,000 dilution. 
The patient became free from symptoms during 
the first series of treatments, and he has re- 
mained free, altho it has been a year since 
the last treatment was given, and a year and a 
half since the last attack. 

Case 12. — F. R. J., a woman, aged 23, had 
had hay-fever throughout the year for fifteen 
years, and for the last nine years she had known 
that cats caused her to sneeze, and made her 
eyes and nose run. 

[324] 



FOEMS OF TEEATMENT 

Cutaneous tests were positive with the eat hair 
protein. She was, however, more sensitive to the 
peptone. A 1 : 100,000 dilution gave a positive 
test. 

Six weekly treatments were given with cat 
hair peptone in a dilution of 1 : 1,000,000. After 
this a 1 : 100,000 dilution was given as follows : 
0.1, 0.15, 0.2, 0.25, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8 
and 0.9 c.c. During this series of treatments 
the patient noted slight hay-fever symptoms 
when she petted a cat. A similar series of treat- 
ments was given with a 1 : 10,000 dilution of the 
peptone. During this series of treatments she 
noted that she could fondle cats without any 
symptoms, and that she had no symptoms when 
not near cats, as used to be the case. Cutaneous 
tests were now positive with a 1 : 1,000 dilution 
of the peptone, whereas previous to treatment a 
1 : 100,000 dilution gave a positive test. 

Naturally, it is easier to avoid cats than 
horses, and it is preferable to dispense with the 
offending cat than to take treatment. The 
protocols show, however, that if it is necessary 
to desensitize against cat hair, the treatment for 
cat hay-fever is no different from that for horse 
hay-fever, and that the results obtained are 
equally as satisfactory. 

PERENNIAL HAY-FEVER CAUSED BY FEATHERS 

In testing patients for sensitization to 

feathers, the protein and the peptone of both 

chicken and goose feathers should be used. The 

patient comes in contact with feathers chiefly 

[325] 



HAY-FEVER 

through the use of feather pillows, which may 
contain either or both kinds of feathers. Only 
two protocols will be given: one illustrating 
feather pillows and the other illustrating a par- 
rot as well as feather pillows as the cause of 
symptoms. 

Case 13. — S. G., a man, aged 30, had had 
hay-fever for the last two years, with only one 
or two days' freedom at any one time. His 
eyes itched and watered, his nose ran and he 
sneezed. He also had frequent head colds. 

Cutaneous skin tests were positive with both 
proteins of chicken feathers, but negative with 
all other proteins. 

Since discontinuing the use of feather pillows 
for the last six months he has been free from 
symptoms. 

Case 14. — R. H., a boy, aged 17, had had 
sneezing, running of the eyes and nose, and fre- 
quent attacks of bronchitis for the last three 
years, and during the last six months he had 
had considerable asthma. His nose had been 
operated on several times without benefit. 

Cutaneous tests were positive with the pro- 
teins of chicken feathers alone. 

On discontinuing the use of feather pillows, 
his symptoms were greatly improved but not 
relieved. The patient then mentioned that 
there was a parrot at his home, and he asked 
whether this could not cause symptoms. The 
parrot was then disposed of, and since then he 
has been entirely free from symptoms. 

Altho feather pillows and parrots may 

[326] 



FORMS OF TREATMENT 

not frequently be the cause of hay-fever symp- 
toms, it is desirable to test with feather pro- 
teins and to inquire in regard to the presence of 
feathered animals at the patient's home. There 
is no question that feather dust penetrates the 
coverings of pillows, and for this reason patients 
who are sensitive to feathers should use a floss 
pillow. 

PERENNIAL HAY-FEVER CAUSED BY OTHER ANIMALS 

Altho I have not had cases of hay-fever 
caused by dogs or by the wearing of furs, such 
instances probably do occur. Hay-fever among 
laboratory workers who are around rabbits and 
guinea-pigs is not rare. I have tested four 
laboratory workers who had hay-fever ; two were 
sensitive to rabbit hair and two to guinea-pig 
hair. All four patients were previously exposed 
to these animals the greater part of each day; 
but, since avoiding these animals, they have 
been free from symptoms. For the last two 
years these patients have had to handle these 
animals only occasionally, and only when hand- 
ling the animals do they have symptoms. In- 
quiry should always be made as to whether 
there are any pet animals in the patient's home. 

PERENNIAL HAY-FEVER CAUSED BY FOODS 

It is not uncommon for bakers to have hay- 
fever symptoms from the inhalation of the 
cereal grain flours, and it is not rare among 
housewives. Therefore the cereal grains should 
[327] 



HAY-FEVER 

always be tested. Foods that are eaten some- 
times cause hay-fever symptoms, but such in- 
stances are not so common as are those caused 
by the inhalation of the proteins. Protocols 
illustrating interesting cases of hay-fever 
caused by the inhalation and ingestion of food 
proteins follow. 

Case 15. — M. T., a woman, aged 40, had had 
nasal trouble all of her life; her symptoms con- 
sisted of stoppage and plugging of the nose, 
thick secretion from the nose, running of the 
nose, and sneezing. For the last few months 
these symptoms had become so aggravated that 
they resembled a perpetual head cold, and con- 
sequently no one would employ her in a 
household. 

Cutaneous tests were positive with chicken 
and goose feather protein and with oat and 
wheat globulin ; all other proteins were negative. 

Omission of feather pillows alone relieved 
her considerably, and omission of oat and wheat 
from her diet completely relieved her symptoms. 

Case 16. — G. C. P., a woman, aged 48, had 
had sneezing, running of the nose and some 
itching and watering of the eyes for the last 
year. During this time she had craved and had 
eaten raw carrots in quantities. 

Cutaneous tests were positive with the pro- 
tein of raw carrots, but they were negative with 
cooked carrots and with proteins of all other 
foods, as well as with those of animal emanations 
and pollens. 

[328] 



FOEMS OP TREATMENT 

Since she has discontinued eating raw car- 
rots, she has been free from symptoms. 

Case 17. — S. B., a woman, aged 55, had had 
hay-fever for the last four years; during the 
winter it was paroxysmal, but during the sum- 
mer it was constant. After a positive cutaneous 
test had been obtained, the patient volunteered 
the information that during the summer she was 
a baker in a hotel, but during the winter her 
occupation was housework which required her 
to bake less frequently; therefore the hay-fever 
symptoms coincided with her baking. 

Cutaneous tests were positive with wheat 
globulin only. 

Case 18. — G. P. W., a woman, aged 30, had 
swelling of the eyes, sneezing and running of 
the nose when she prepared or ate raw celery. 
She also had hay-fever caused by ragweed pollen. 

Cutaneous tests were positive with a protein 
of celery and ragweed pollen. 

Case 19. — A. W., a woman, aged 52, had had 
sneezing, running of the nose and eyes, and dul- 
ness in her head for seventeen years until she 
recently learned that these symptoms were 
caused by eating certain foods, namely, pork, 
onions, oatmeal and some forms of pastry. 
Sifting rye flour caused hay-fever, but she had 
no symptoms from eating it. 

Cutaneous tests were positive with the fol- 
lowing proteins and none others: barley, oat, 
wheat, onion, pork and cantaloup. 

Since avoiding these foods she has been free 
from symptoms. 

[329] 



I 



HAY-FEVER 

Case 20. — H. M., a woman, aged 37, had had 
hay-fever or a cold for six years whenever she 
mixed and baked bread. She had no trouble 
from eating pastry. 

Cutaneous tests were positive with the cereal 
proteins, namely, rye, rice, barley, corn and 
wheat. All of the six individual proteins of 
wheat gave positive reactions. 

Omission of cereals from her diet was not suffi- 
cient to permit her to bake without symptoms, 
nor did subcutaneous inoculation with the indi- 
vidual wheat proteins or with the protein of the 
whole wheat render her immune, altho fol- 
lowing this treatment she could bake a little 
with comparative diminution of her symptoms. 
However, relief was not sufficient to warrant 
further treatment, since it was not essential that 
she continue baking. 

Case 21. — ^W. R. M., a man, aged 47, had had 
attacks of sneezing and running of the eyes and 
nose for many years whenever he was exposed to 
flour dust. 

Cutaneous tests were positive with wheat 
globulin, but were negative with all other 
proteins. 

Several of the cases in the foregoing protocols 
are worthy of special attention. Case 21 pre- 
sented symptoms of vasomotor rhinitis for years, 
and not until cutaneous tests were made was the 
actual cause determined. In Case 19, symptoms 
were also due to the ingestion of commonly eaten 
foods; but the patient was aware of the cause, 
and cutaneous tests verified the cause. In Cases 

[330] 



FOEMS OF TREATMENT 

16 and 18 there were symptoms only after the 
eating of less common foods. In Case 17 the 
cutaneous tests determined the cause of symp- 
tons. In Case 20 an attempt was made to de- 
sensitize the patient by subcutaneous inoculation 
so that she might inhale wheat flour without 
symptoms; this treatment was a failure. In all 
food sensitization cases it seems advisable to 
omit the offending protein, and usually this is 
not difficult to do. Case 21 illustrates a con- 
dition which is frequently present in bakers 
and is not rare among housewives. 

PERENNIAL HAY-FEVER CAUSED BY POLLENS 

It is not uncommon for seasonal pollen hay- 
fever patients to have paroxysms of hay-fever 
and frequent head colds of two or three days' 
duration throughout the year. The exciting 
causes of the attack out of pollen season are ex- 
posure to dust, sudden changes in the tempera- 
ture, frosty air, drafts, irritating odors and the 
like. Following successful treatment for the 
seasonal pollen hay-fever, these patients usually 
remain free from symptoms during the ensuing 
year. It would seem that exposure and sensi- 
tization to the pollens had in some way rendered 
the patients' mucous membranes susceptible to 
or sensitive to the secondary or minor causes. 
Therefore, pollens may be a cause of hay-fever 
outside the pollen season, and such patients may 
be relieved of perennial hay-fever by successful 
pollen treatment. 

[331] 



HAY-FEVER 

PERENNIAL HAY-FEVER CAUSED BY UNUSUAL 
PROTEINS 

Goodale* has observed several cases of hay- 
fever caused by the inhalation of orris root face 
powder; these patients gave positive cutaneous 
tests with both the powder and the crude orris 
root. I have observed one patient who was sensi- 
tive to rice, and the use of face powder contain- 
ing rice flour caused symptoms. The following 
protocol of a case that I studied illustrates the 
i'act that perennial hay-fever may be due to the 
inhalation of any kind of organic substance. 

Case 22. — T. G., a man, aged 34, a jewel 
polisher, had had sneezing, running of the nose, 
and a stuffy feeling in his head for five years. 
The symptoms occurred while he was at work, 
but he was free after leaving his work and 
whenever he took a vacation from his work. 
While at work the patient was exposed to con- 
siderable boxwood dust, which is very fine and 
floats in the air. 

The patient gave positive cutaneous tests with 
the protein obtained from the boxwood dust in 
a dilution of 1 : 30,000. 

After several inoculations with a 1 : 40,000 
dilution of the boxwood protein the patient be- 
came free from sjniiptoms while at work. Treat- 
ment was continued until the patient was tak- 
ing a 1 : 1,000 dilution of the protein, and he 
continued to be free from symptoms. 

^Goodale, J. L. Boston M. C. S. J. 175: 181 (Aug. 10) 
1916. 

[332] 



FORMS OF TREATMENT 

PEEENNIAL HAY-FEVER CAUSED BY BACTERIA 

Twenty patients who had hay-fever symp- 
toms throughout the year caused by bacteria 
have been studied. Bacteria were considered to 
be the cause of symptoms for these reasons : The 
patients were not sensitive to any of the usual 
proteins to which they were exposed, namely, 
those of the common foods, animal emanations 
and pollens. Either repeated examination of 
the nose and sinuses had revealed no abnormal- 
ities, or repeated operations had previously 
removed and corrected all abnormalities. Fi- 
nally, many of these patients were either greatly 
benefited or relieved by autogenous vaccines 
made from the nasal secretion. This type of 
case differs from those already discust in this 
paper in that none of the patients were sensi- 
tive to any protein, and eye symptoms were not 
present. As already noted, all of the previous 
groups of patients had, in addition to nasal 
symptoms, itching and running of the eyes, 
whereas this bacterial group had little or no 
eye trouble. Therefore, the presence of pro- 
nounced eye symptoms indicates probable sensi- 
tization to some protein, and absence of eye 
symptoms indicates the improbability of sensi- 
tization to a protein as a cause. It would seem 
that this group of so-called bacterial cases should 
more properly be called vasomotor rhinitis 
rather than hay-fever, in that they differ as 
already noted from the sensitization cases. 

Of the twenty bacterial cases that I studied, 

[333] 



HAY-FEVER 

ten were treated by autogenous nasal vaccines 
with great benefit or relief; five patients who 
were similarly treated were not benefited at 
all, and the remaining five were not treated by 
vaccines but were treated locally by rhinologists 
without any benefit; the latter five cases serve 
as controls for those treated with vaccines. It 
is not my intention to infer that rhinologists, by 
means of local and operative treatment, fail 
to benefit or even cure similar cases, because 
it is well known that the rhinologist does not 
often fail in such cases. What I do, however, 
wish to infer is that after all other treatment 
has failed, autogenous vaccine treatment may 
result in considerable benefit or even relief; at 
least vaccine treatment is worthy of a trial as 
a last resort. Protocols of the ten cases in which 
treatment with autogenous vaccine gave bene- 
fit follow: 

Case 23, — S. F. S., a woman, aged 27, had 
had attacks of "hay-fever" for five years. The 
attacks consisted of sneezing and running of the 
nose for fifteen minutes every morning on aris- 
ing and every evening on retiring. 

Cutaneous tests were negative with proteins 
of foods, pollens and animal emanations. 

Treatment was given at weekly intervals with 
an autogenous vaccine made from the patient's 
nasal secretion; the vaccine consisted of hemo- 
Ij^ic streptococci. The first inoculation was 300 
million, and each succeeding week the amount 
was increased 100 million. 
[334] 



FORMS OF TREATMENT 

The patient began to improve after the first 
treatment, and has continued to improve until 
she became free from symptoms following the 
seventh treatment. 

Case 24. — D. A. H., a woman, aged 18, had 
had "hay-fever" for several years; she had a 
head cold most of the time, she sneezed and her 
nose was irritated and ran. 

Cutaneous tests were negative with all of the 
common proteins. 

As in the former case, treatment was given 
with an autogenous nasal vaccine consisting of 
a hemolytic streptococcus. 

She became free from symptoms and re- 
mained free for five months until the cold win- 
ter weather set in, when she began to sneeze 
considerably, although she had no irritation or 
running of the nose. 

Case 25. — F. W. H., a woman, aged 49, had 
had no hay-fever all through the year for twenty 
years, but lately she had been worse during the 
summer. Her eyes itched, her nose ran, she 
sneezed and her ears itched; these symptoms 
continued for two or three days at a time with 
a few days' interval between the attacks. 

Cutaneous tests with all the common proteins 
were negative. 

After five treatments, as in the preceding 
cases, with an autogenous vaccine made from 
her nasal secretion, she became free from symp- 
toms and remained free without treatment for 
eight months. The vaccine consisted of Strepto- 
coccus viridans. The patient then had a return 
[335] 



HAY-FEVER 

of the former symptoms, but again she was re- 
lieved by similar treatment. 

Case 26. — W. D. R., a woman, aged 34, had 
had hay-fever throughout the year for three 
years; her eyes ached but did not water, her 
nose ran, and she sneezed every morning. Dust 
irritated her nose, and night air irritated so 
much that her sleep was disturbed. 

Cutaneous tests were negative with all 
proteins. 

She was given twelve treatments as in the 
preceding cases with an autogenous hemolytic 
streptococcus vaccine made from her nasal secre- 
tion. She became very much freer from symp- 
toms, and her nights were entirely free. 

Case 27. — I. F., a boy, aged 18, had had 
** hay-fever" for five years, winter and summer. 
Each attack might last one day or one week, 
and consisted of sneezing, running of the nose 
and eyes, and swelling of the eyes. He had 
frequent colds in his head and nose. 

Cutaneous tests were negative with all 
proteins. 

A culture from the nasal secretion inoculated 
in dextrose bouillon and on dextrose agar con- 
sisted of a pure growth of Staphylococcus 
pyogenes-albiis. An autogenous vaccine made 
from this organism was given at weekly intervals 
for six weeks; the first dose was 500 million, 
and this was increased each week by 250 million. 
The patient became practically free from symp- 
toms and had continued free for eight months 
when last heard from. 

[336] 



FOEMS OF TREATMENT 

Case 28. — M. F., a girl, aged 14, had had 
colds in her head like "hay-fever" all the year 
for as long as she could remember, with the 
exception that she was free for a period of three 
or four years following the removal of adenoids. 

Cutaneous tests with proteins were negative. 

Her nasal secretion planted on dextrose agar 
grew practically a pure culture of Staphyloccoc- 
cus pyogenes-alhus. At weekly intervals she was 
given twelve treatments with an autogenous 
vaccine of this organism in gradually increasing 
amounts; the first dose was 500 millions, and 
this was increased each week by 250 million. 
During this treatment the patient became free 
from symptoms and still was free when last 
heard from a year after treatment was discon- 
tinued. 

Case 29. — 0. 0., a man, aged 36, had had 
*' hay-fever" for fifteen years; it developed 
gradually and occurred at all times of the year. 
The attacks consisted of sneezing, running of 
the nose, swelling of the nasal mucous mem- 
brane and swelling and itching of the eyes. The 
attacks continued for two or three hours. He 
also had frequent head colds. 

Cutaneous tests were negative with proteins; 
intradermal tests were somewhat positive with 
Staphylococcus pyogenes-alhus, but negative 
with other bacteria. 

Following a series of eight treatments as in 
the previous case with a vaccine of Staphylococ- 
cus pyogenes-alhus, the attacks became much 
less violent, and the sneezing and nasal secre- 
[337] 



HAY-FEVEE 

tion were greatly diminished. A year later the 
attacks became violent again and the patient 
requested more treatment. Staphylococcus 
pyogenes-alhus vaccine was again given with 
equally good results. 

Case 30. — H. C, a woman, aged 21, had had 
almost continuous head colds for three years; 
her eyes smarted, she sneezed, and she had a 
watery and sometimes bloody secretion from the 
nose. Cutaneous tests were negative with all 
proteins. 

Treatment was given a few times with a stock 
vaccine consisting of Staphylococcus pyogenes- 
axireiis, with no benefit. Twelve treatments were 
then given with an autogenous vaccine of a 
gram-negative bacillus isolated from the nasal 
secretion. During treatment with this organism 
the patient gradually became free from symp- 
toms and remained free for a year after the 
vaccine was discontinued. She has not been 
heard from since. 

Case 31. — A. H. L., a woman, aged 38, had 
had ''hay-fever" the year round for many 
years. She sneezed, her nose filled up, and it 
felt as if it were stuffed with cotton and then it 
ran mucus virtually every morning. For the 
last six years she had not had the sense of smell 
or taste, and her ears felt as if they were 
filled up. 

Cutaneous tests were negative with all 
proteins. 

An autogenous vaccine consisting of a hemo- 
lytic streptococcus was made from the thick 
[338] 



FOEMS OF TREATMENT 

secretion from the nose and nasopharynx and 
sent to her physician, a nose and throat special- 
ist, who carried out the treatment and later 
reported that the patient was greatly relieved 
of symptoms. 

Case 32. — W. C. H., a man, aged 32, had had 
a watery secretion from the nose and sneezing 
continuously for a year. 

Cutaneous tests were negative with all 
proteins. 

An autogenous vaccine consisting of a hemo- 
lytic streptococcus and Staphylococcus pyogenes- 
aureus was made from the patient's nasal secre- 
tion. This vaccine was administered by the 
patient's physician, a nose and throat special- 
ist, who later reported that the patient became 
free from symptoms. 

These cases illustrate the points already men- 
tioned in connection with the bacterial cases. 
It is noted that in Cases 25 and 29 relapses oc- 
curred several months after treatment was 
stopt, but on resumption of previous treat- 
ment both patients again became free from symp- 
toms. In Case 30 the patient was not benefited 
by a stock vaccine consisting of Staphylococcus 
pyogenesaureus, but was relieved by an auto- 
genous nasal vaccine consisting of a gram-nega- 
tive bacillus. 



[339] 



HAY-FEVER 

OLFACTORY VASOMOTOR RHINITIS, OR PSEUDO- 
HAY-FEVER 

Goodale" has called attention to the fact that 
during pollen seasons certain individuals who 
are sensitive to and have hay-fever from, pol- 
lens also have vasomotor symptoms ranging from 
sneezing to asthmatic attacks due to the fra- 
grance of certain heavily scented flowers that 
have no pollen or to which pollen the individual 
is not sensitive. He considers that the symp- 
toms are reflex and that the path of transmis- 
sion is along the olfactory nerve. The flowers 
most commonly responsible are lilies, hyacinths, 
sweet peas and peonies. 

It is not infrequent to encounter certain 
individuals who have symptoms from similar 
causes at any time of the year. The causes of 
symptoms may be classified as mechanical, chemi- 
cal, odorific and thermal. Among the mechani- 
cal causes any kind of dust is the most frequent 
cause, more especially sweeping dust and hay 
dust; fine powder, such as talcum and the like, 
is also a frequent cause. Among the chemical 
irritants, soap powder, lye and ammoniacal 
fumes are very frequent causes. Among the 
odorific irritants, heavily scented perfumes, face 
powders, musty air and stable odors are fre- 
quent causes. Thermal irritants concern sudden 
changes of temperature, as in going from warm 

'Goodale, J. L. Boston M. & S. J. 175: 181 (Aug. 10) 
1916. 

[340] 



FOEMS OF TEEATMENT 

air to extreme cold, from moist air to very dry air, 
and exposure to drafts ; a very frequent history 
is that of a paroxysm of sneezing with or with- 
out running of the nose on retiring and on aris- 
ing. The mechanism seems to be a reflex due to 
the sudden exposure of the warm and protected 
skin of the body to cold air, as in getting out 
of bed and in undressing, during which acts 
the warm body surface is suddenly and mo- 
mentarily exposed to cool air; in other words, 
there is a mild chilling of the body surface. The 
same mechanism holds for many who take cold 
easily. Some of these patients are sensitive to 
some type of protein which may have rendered 
their nasal mucous membranes sensitive to these 
irritants; others are not sensitive to proteins. 
Appropriate protein treatment for those who 
are sensitive usually relieves these symptoms, no 
matter what the irritant may be, and occasion- 
ally autogenous nasal vaccines will benefit or 
relieve the non-sensitive individual. Again, it 
may be well to call attention to the fact that I 
am dealing with nasal conditions other than 
those due to abnormalities, growths and the like, 
which may cause similar symptoms. I am con- 
sidering only those cases in which no abnormali- 
ties other than a possibly congested mucous 
membrane could be demonstrated or those whose 
apparent abnormalities had been corrected. 



[341] 



HAY-FEVER 

CONJUNCTIVITIS DUE TO FOOD PROTEINS 

Conlon' reports three cases of conjunctivitis 
unaccompanied by any other manifestations that 
were caused by eating certain foods, and the 
patients gave positive cutaneous tests with the 
respective protein. One protocol follows: 

A. B. R., a man, aged 56, merchant, for the 
last four or five years, had been unable to read 
for more than five minutes at a time without, as 
he exprest it, a feeling of sand in his eyes; 
the lids felt constantly as they do when one is 
very sleepy. He had frequent, sudden attacks 
of lacrimation, which came on without any 
known cause and stopped as suddenly as they 
started. He said that he had had a perfectly 
miserable time of it for the last couple of years, 
with virtually constant eye discomfort; so he 
became an "early to bed and late to rise" sort 
of fellow, as the only time he was at all com- 
fortable was when his eyes were closed. His 
glasses had been changed a number of times, 
tinted lenses had been ordered and worn, and 
drops of various kinds and colors had been 
prescribed and used without any benefit whatso- 
ever. The eyelids were slightly swollen and 
congested, and there was a general enlargement 
of the conjunctival blood vessels which was more 
marked on the bulbar conjunctiva. Nothing 
was found in the nose or throat. The general 
condition was good. He had no bad habits, did 

"Conlon, F. A.: Am. Jour. Ophth. 2: 486 (July) 1919. 
[342] 



FORMS OF TREATMENT 

not smoke or drink, and no change was found 
necessary in his glasses. 

On a recent skin test with more than thirty 
proteins, this patient reacted to egg alone. 

The elimination of eggs from his diet was 
shortly followed by a total disappearance of his 
annoying symptoms. For the last two years he 
has been able to use his eyes as he wished, and 
he reports that life is once more worth living. 
One control test (eating egg) was followed by a 
return of his symptoms. 

Conlon makes the following comments on this 
group of cases: 

The skin test should be made at the time the 
patient is suffering from the conjunctivitis, as in 
some people the anaphylactic reaction disappears 
after the patient abstains from the offending 
food any length of time, to reappear again on 
eating it. 

In the absence of uncorrected ametropia, all 
recurring low grade inflammation of the con- 
junctiva which the patient calls "frequent at- 
tacks of red eyes" should be considered as pos- 
sibly due to food anaphylaxis. This is especially 
true when the attacks appear the same months 
year after year. After obtaining a positive skin 
test, the proof as to this food being the cause 
of the conjunctivitis is readily obtained by the 
patient. 

Conlon also believes that the study of food 
protein anaphylaxis and bacterial protein ana- 
phylaxis will explain the etiology of a number 
of eye diseases, especially keratitis and low 
[343] 



HAY-FEVER 

grade inflammations of the uveal tract, and will 
open up vast and fruitful fields for investi- 
gation. 

CONCLUSIONS 

Perennial hay-fever is frequently caused by 
animal emanations, and cutaneous tests should 
be made with the common animal epidermal 
proteins. 

Those patients whose hay-fever is caused by 
exposure to horses may be successfully treated 
by repeated inoculation in gradually increasing 
amounts of the particular epidermal protein to 
which they are most sensitive. 

Those patients who are sensitive to cat hair 
protein may be treated similarly with equal 
success. Dispensing with the cat, however, is 
easier of accomplishment and is usually bene- 
ficial. 

With those who are sensitive to the epidermal 
proteius of other animals (pets), it is prefera- 
ble to avoid that particular animal. Sensitiza- 
tion to feather protein from feather pillows is 
frequent, and the substitution of floss pillows is 
desirable. 

Perennial hay-fever is frequently caused by 
the ingestion of foods and by the inhalation of 
the cereal grain flours. Cutaneous tests often 
reveal such a cause, and omission of the protein 
is the desirable mode of treatment. 

Patients who have seasonal pollen hay-fever 
frequently have paroxysmal symptoms through- 
out the year. Satisfactory preseasonal treatment 
[344] 



FOEMS OF TREATMENT 

with the particular pollen that causes the sea- 
sonal hay-fever frequently relieves the peren- 
nial symptoms. 

Kecurring head colds are frequently coincident 
with the foregoing sensitizations, and relief 
from these head colds usually follows proper 
treatment, as already outlined. This type of 
head cold is probably not due to an infection but 
rather a result of sensitization which renders the 
nasal mucous membrane easily irritable. 

Non-sensitive patients with perennial hay- 
fever or vasomotor rhinitis, provided there are 
no demonstrable abnormalities, growths and the 
like in the nasal cavities or sinuses, are some- 
times benefited or relieved by autogenous vac- 
cines made from the nasal secretion. The same 
statement also holds true for those patients who 
are subject to frequent head colds. 

Olfactory vasomotor rhinitis, or pseudo-hay- 
fever, caused by mechanical, thermal, chemical 
and odorific irritants, is not uncommon and 
should be recognized. 

The ingestion of foods may cause symptoms 
referable to the eyes alone. Therefore, altho 
protein sensitization should not be considered 
as a "cure all' or a cause of all obscure condi- 
tions, the cutaneous test for protein sensitiza- 
tion deserves a place among diagnostic tests; 
and when properly performed and interpreted, 
it is a very useful test. 

483 Beacon Street. 

[345] 



HAY-FEVEE 

9. The Calcium Salt Treatment 
By Harold Wilson, M.D.^ 

The reports of Emmericli and Loew' on the 
very favorable results secured by them from the 
prolonged administration of calcium chlorid in 
the treatment of hay-fever induced me to make 
some trial of this drug during the season of 
1915. A brief report of the results will be given 
in this communication. 

Whether the ingestion of calcium salts has a 
direct inhibitory action on the proteolytic reac- 
tions which appear to be a necessary part of the 
hay-fever complex, or so modify this reaction 
as to render the split proteins less toxic, or 
whether they act by lessening the patient's 
nerve irritability, seems at this time to be quite 
undetermined. The employment of calcium 
salts in hay-fever would be on a much better 
basis if we were able to rationalize it. At 
present, it seems to me that this method of 
treatment can hardly claim to be more than 
"reasonable empiricism." In view of the fact, 
however, that much other useful therapy rests 

* Gouty and rheumatic cases are undoubtedly much 
benefited by the use of calcium salts as Dr. Wilson points 
out in this article. 

'Emmerich and Loew: Erfolgreiche Behandlung des 
Heufiebers durch lange Zeit fortgesetzte Chlorkalzium- 
Zufiihr, Miinchen. med. Wchnschr., 1913, Ix, 2676; Wie- 
tere Metteilungen iiber Erfolgreiche Behandlung des 
Heufiebers, ibid., 1914, Ixii, 41. 
[346] 



FORMS OF TREATMENT 

on a no more secure foundation than this, there 
is no reason why we should not make a sufficient 
trial of this method, which has, certainly, many 
practical advantages. 

Twenty-six patients were treated by me dur- 
ing the past season. Of these, twenty-two were 
treated exclusively with calcium chlorid, and 
four patients, who had been under treatment 
by means of injections of pollen solution, were 
given the drug when their hay-fever symptoms 
began to develop more or less severely. 

One patient had hay-fever of the vernal type 
only; three patients had both vernal and au- 
tumnal attacks, and twenty-two patients had 
only autumnal attacks. Twenty-two patients 
gave a positive ophthalmic or cutaneous reaction 
to ragweed pollen; four gave a negative reac- 
tion to ragweed. Many cutaneous tests were 
made with substances other than pollens, the 
result of which will be made the subject of 
another report. 

Treatment was begun in June, with seven 
patients; in July with four; in August with 
fifteen, and in September with two. In no case 
did smy patient take the drug for more than 
eight or ten weeks before the time of the ex- 
pected attack, and in most cases the period was 
much more brief. Emmerich and Loew advise 
the use of the drug over a very long period, as 
much as a year, if possible. Altho it has been 
shown that the maximum calcium retention in 
the system occurs only after its prolonged in- 
gestion, it remains to be proved that its optimum 
[347] 



HAY-FEVER 

therapeutic effect in hay-fever requires its daily 
use for a year before the expected attack. In 
some of the most favorable cases here reported, 
the relief secured came almost at once, or after 
taking, at most, only a few doses. 

For most patients the calcium chlorid was 
prescribed thus: 

Calcium chlorid crystals 100 gm. 

Distilled water to make 500 c.c. 

M. siG. — Take one teaspoonful in sufficient water with 
or after each meal. 

This gives the patient about 3 gm. of calcium 
chlorid daily. The crystalline salt is used in 
preference to the anhydrous, as making a cleaner 
and clearer solution. When the anhydrous salt 
is prescribed, allowance should be made for the 
water of crystallization, of which in the crys- 
talline salt there are six molecules (CaCl3-|-6 
H.O): 

Calcium chlorid, anhydrous 50 gm. 

Distilled water to make 500 c.c. 

M. SIG. — Take one teaspoonful in sufficient water with 
or after each meal. 

There was no serious difficulty in taking the 
drug as thus prescribed. One patient experienced 
gastric distress until the dose was reduced; an- 
other complained of weakness and loss of appe- 
tite, and had to use it intermittently in a 
lessened dose; another thought it caused a 
diminution in the urinary output, while another 
thought the flow of urine was increased. It has 
[348] 



FORMS OF TREATMENT 

not been observed that the daily ingestion of 
3 gTQ. of calcium chlorid has been followed by 
any marked bodily disturbance. In fact, much 
larger doses than this can apparently be taken 
with entire safety. Cow's milk contains 0.198 
per cent, calcium monoxid. A pint of milk 
contains about 0.71 gm. calcium. Three gm. of 
calcium chlorid crystals contain about 0.55 gm. 
calcium, so that more lime is taken by the daily 
use of a pint of milk than in the dosage pre- 
scribed above. 

The table on page 350 gives the results of 
the treatment with calcium chlorid in the 
twenty-six cases under observation. 

A few of the most favorable reports are given 
in greater detail: 

Case 23.— Miss M. T., aged 21, had had hay- 
fever since childhood, beginning in May and 
lasting until frost. She was sensitive to flowers 
of all kinds, to dust and to wind. She could not 
sweep floors without marked discomfort. She 
had no asthma. Eye and nasal symptoms were 
most marked. She had been using epinephrin 
solutions until they now aggrevated the trouble. 
July 2d there were lacrimation, coryza and 
sneezing of moderate severity more or less con- 
tinuously. Ophthalmic and cutaneous reactions 
to ragweed were negative. Calcium chlorid, 1 
gm., three times a day, was prescribed. July 
9th, eyes were "wonderfully better"; there were 
somewhat less sneezing and coryza ; the patient 
was less sensitive to dust and wind. July 
20th she was much less uncomfortable than 

[349] 



HAY-FEVEE 



RESULTS OF TREATMENT WITH CALCIUM CHLORID IN 
TWENTY-SIX CASES.* 





Type 


Reac- 


Duration 






Case 
No. 


of 
Hay- 


tion 
to 


of 
Treat- 


Result 


Remarks 




fever 


Rag- 
weed 


ment 






12 


A 


+ 


2-3 weeks 


+ 


Under treatment with injections of 
pollen solutions for ten weeks 
previously. 


13 


A 


+ 


2-3 weeks 


+ 


Previous treatment as in Caae 12. 


14 


A 


+ 


2-3 weeks 


+ 


Previous treatment as in Case 12. 


19 


A 


+ 


2-3 weeks 


+ 


Previous treatment with injections 
of pollen solutions seven weeks. 


22 


A 


+ 


10 weeks 







23 


A-V 




13 weeks 


+ + + 


Immediate improvement and abso- 
lute freedom from all symptoms 
after July 28. 

Multiple sensitization. 


24 


A 


+ 


11 weeks 


+ + + 


25 


A 


+ 


13 weeks 


+ 


No symptoms until September 1. 


26 


A 


+ 


16 weeks 


+ + + 


No symptoms xmtil September 25. 
Then only trifling itching in throat 
and slight sneezing. No other 
symptoms. 


27 


A 


+ 


12 weeks 


— 


September 25, patient writes, "I 
was worse than usual." 


29 


A 


+ 


8 weeks 


+ + -{- 


Only slight symptoms. 


30 


A 


+ 


3 weeks 


+ 




31 


A 


+ 


9 weeks 


+ 


Multiple sensitization (faint). 


32 


A 


+ 


4 weeks 


+ 


Multiple sensitization. 


33 


V 




9 weeks 


+ + 


Immediate relief and practical free- 
dom from all symptoms about 
half the time. 


34 


A-V 


+ 


5 weeks 


+ 


Reports moderate relief from symp- 
toms during season. 


35 


A 


+ 


4 weeks 


+ 


Multiple sensitization. 


36 


A 


+ 






No report. 


37 


A 


+ 


5 weeks 


+ + 


Very little hay-fever, even in 

country. 
Multiple sensitization. 


38 


A 


+ 


4 weeks 


+ 


39 


A 


+ 


4 weeks 


+ 




40 


A 


+ 


4 weeks 


+ + 


Multiple sensitization. 


41 


A 


+ 


4 weeks 


+ + 


Did not take drug regularly. 


42 


A 




5 weeks 


+ + + 


Peach reaction positive; stopped 
eating peaches. 


43 


A 


+ 


2 weeks 


+ 


Left city early in September. 


44 


A-V 




13 weeks 


+ + + 


Relief immediate and complete; 
slight recurrences; took drug very 
irregularly. 



♦Explanation of signs: A indicates autumnal; V, vernal; • — , symptoms 
worse than usual; 0, symptoms about the same as usual; +, symptoms less 
marked than usual; -i--t-> symptoms much less marked than usual; very 
definite improvement; 4-4-+. absolute freedom from symptoms, or only 
trifling and insignificant ones during season. 

[350] 



FOEMS OF TREATMENT 

usual. On the whole, there was a marked 
amelioration of symptoms. July 28th there 
was very great relief. The patient was prac- 
tically free from all symptoms. "I never 
was so helped by anything before." August 
13th, the patient reported that she had had 
no hay-fever symptoms whatever since last visit. 
Relief was absolute. September 6th, absolute 
freedom from symptoms continued. This relief 
continued throughout the season. 

Case 26.— Miss M. R., aged 25, had had au- 
tumnal hay-fever seven or eight years; no 
asthma. Maternal aunt had had hay-fever since 
childhood. Ophthalmic and cutaneous reactions 
to ragweed were positive. June 11th, calcium 
chlorid was prescribed, 1 gm. three times a day, 
but owing to some gastric distress which it 
seemed to cause, the dose was much reduced for 
several weeks. The full dose, however, was taken 
later and continued. No hay-fever symptoms 
were experienced until September 5th, when 
there was slight sneezing, and itching in the 
throat. During the rest of the season symptoms 
were practically absent. 

Case 29.— Dr. W. A. K., aged 40, had had 
autumnal hay-fever for fifteen years, and slight 
asthma recently. July 7th, calcium chlorid was 
prescribed, 1 gm. three times a day. Patient 
reported in October that he had experienced 
only trifling symptoms at any time during the 
season. 

Case 33. — Miss F. P., aged 43, had had vernal 
hay-fever, usually beginning about June 1st 
[351] 



HAY-FEVER 

and lasting until the end of July. June 12th, 
she was having about the usual amount of trou- 
ble. The ophthalmic reaction to ragweed was 
negative. Calcium chlorid, 1 gm. three times a 
day, was prescribed, with much relief, almost 
at once. She reported, August 25th: "I have 
been practically free from symptoms about half 
the time. The rest of the time partly free and 
partly in trouble. About July 28th took a long 
railway journey, weather dry and dusty, with no 
hay-fever symptoms at all." 

Case 42.— F. W., aged 28, had had hay-fever, 
beginning in August, for several years. Father 
had hay-fever; no asthma. Ophthalmic and 
cutaneous reactions to ragweed were negative. 
Cutaneous and nasal reaction to peaches was 
positive. Calcium chlorid, 2 gm. three times a 
day, was prescribed. August 25th, the patient 
was very comfortable, with scarcely any symp- 
toms. Cutaneous reaction to peaches was nega- 
tive. The patient had stopt eating peaches. 
During the rest of the season there were very 
few hay-fever symptoms. 

Case 44. — Miss C. S., aged 25, had had hay- 
fever for nine years, beginning in early spring 
and lasting until the second week in October. 
She had asthma. Symptoms were marked. 
June 30th, the hay-fever symptoms were distress- 
ing. Ophthalmic and cutaneous reaction to rag- 
weed was negative. Calcium chlorid, 1 gm. 
three times a day, was prescribed. Patient re- 
ported September 25th. The hay-fever symp- 
toms, which were severe, disappeared after the 
[352] 



FOEMS OF TEEATMENT 

second dose of the medicine, whereupon she 
promptly stopt taking it regnlarly. Afterward 
she took a long auto journey without symptoms. 
During the summer she had occasional slight 
symptoms, which disappeared immediately when 
she took the medicine. She had been practically 
free from all hay-fever symptoms ever since 
beginning to take the drug. She thinks the re- 
sults are "wonderful." She would probably 
have taken the drug more regularly if it had 
not seemed to increase the secretion of urine. 

1. Some hay-fever patients taking not less 
than 3 gm. of calcium chlorid daily, even for a 
short time, are practically relieved from all hay- 
fever symptoms. 

2. Calcium chlorid may be taken in doses of 
3 gm. daily for an indefinite time without any 
apparent injury. 

3. It is not indispensable in all cases for a 
hay-fever patient to take calcium chlorid over 
a long period of time in order to secure relief. 

4. Calcium salts may be given, even when 
the nature of the patient's sensitization is not 
known. 

5. The clinical results from the administra- 
tion of calcium chlorid in cases of hay-fever are 
such as to warrant its further trial. 



10. Surgical Treatment 

Surgical treatment of hay-fever is frequently 
necessary when the patient comes to the physi- 
cian in the midst of the disease and palliative 
[353] 



HAY-FEVER 

measures are not possible. In this case I cauter- 
ize the small sensitive areas with a flat electrode 
at a white heat, and without the use of cocain, 
as the use of a local anesthetic would make it 
impossible to find the sensitive spot. It is well 
to find the sensitive areas with the cold electrode, 
then turn on the current and bring to a white 
heat. In this way you can cauterize four or five 
sensitive areas at one time. Cauterization should 
not be repeated more frequently than every six 
or seven days. 

Nasal catarrh, nasal polypi, deviation of the 
septum, as well as sinusitis, should be treated 
long before the paroxysms. Many authorities, 
including Ballinger, believe sinusitis is hay- 
fever, and, if this is true, selected cases respond 
to autogenous vaccine. Ballinger quotes Dr. 
P. M. Farrington's successful treatment by this 
method. He injects 50,000,000 bacteria at first 
treatment, gradually increasing tjie dose to 
100,000,000 at third treatment. The injections 
should be made every third or fourth day. 

11. A Summary of Treatment 

To one who has read the outlines of treatment 
given in this book it will appear that success in 
the treatment of hay-fever can be reached 
through several avenues, — through sera, surgi- 
cal work, local application and internal medi- 
cines. Preparedness is the watchword of our 
country, and prevention is the keynote in the 
management of hay-fever. I, therefore, believe 

[354] 



FOEMS OF TEEATMENT 

that hay-fever can be prevented by removing the 
stigma of neurotic inheritance and anatomical 
defects in youth and by observing the rules of 
the Hay-Fever Prevention Association, as out- 
lined by Dr. Scheppegrell and quoted in this 
book. The careful study of pollen by Dunbar 
has advanced the possibility of cure by this 
means and will eventually bring about a more 
scientific adjustment of the remedy. At the 
present time, however, treatment has not been 
satisfactory. A more extended study may give 
better results. Dunbar has caused many en- 
thusiastic workers to offer the results of their 
labors, and I have quoted Dr. H. Hays' experi- 
ence with auto-serum, which should be more 
fully tested, and with him, the honest efforts of 
Dr. Manning, Dr. Alexander, and the earnest 
disciple of Dunbar, Dr. J. L. Goodale, whose 
conclusions as follows are the last words on pol- 
len therapy. 

* ' Serobiological methods have shown the 
phylogenetic relationship of the different plant- 
orders and -families. The application of these 
discoveries to the treatment of hay-fever by in- 
jection of plant proteids promises to assist in the 
selection of the specific material required for a 
given case. Definite reactions are elicited in 
hay-fever by the pollen of the exciting plant 
when brought into contact with an abrasion of 
the skin. The intensity of these manifestations 
may be sensibly diminished by the repeated pa- 
renteral administration of the proteids in ques- 
tion. Coincident with the diminution in the skin 

[355] 



HAY-FEVER 

reactions, there seems to occur an increased tol- 
erance of the exposed mucous membrane to the 
pollen the plants employed. Pollen therapy 
in hay -fever may he regarded at the present 
time as a promising method of treatment, hut 
its value and the permanence of its results re- 
main still to he definitely established.'^ 

To secure reasonable success it is important 
that hay-fever patients should begin their treat- 
ment at least three or four weeks before the 
onset of the attack by the use of sedative solu- 
tions ; a strict cleansing treatment being applied 
daily, if possible, to the nasal membrane to in- 
hibit the reflex. This local treatment should 
continue for several weeks. Many patients are 
relieved with the use of a weak solution of 
suprarenal, 1 : 10,000 in normal salt. Again, the 
antiseptic alkaline solution, with an equal quan- 
tity of water, usually is sufficient; many are 
made better by the use of a weak Dobell's 
solution, and this is my choice of a solution. 
The frequency of a reaction causing congestion 
(has rendered an otherwise valuable remedy 
undesirable. I, therefore, have better results 
with mild alkaline solutions of Dobell's, or the 
liquor antisepticus alkalinicus. Again, many 
cases do well on an ointment of suprarenal in 
white vaseline. A small quantity placed in the 
nose will last longer and be more agreeable than 
the solution. In asthmatic patients the ad- 
renalin chlorid in oil, used as a spray, is quite 
effective in selected cases. The danger in the 
use of cocain is too apparent to place it in the 
[356] 



FORMS OF TREATMENT 

hands of the patient. Its use in office work 
is even questionable. 

Many internal remedies have been used, and, 
altho failure is frequent, I have found quinin, 
atropia, strychnin, anti-pyrin, iodids and thyroid 
among those most frequently prescribed. Quinin 
is valuable in massive doses, both locally (snuffed 
up the nostril in powder form) and internally. 
The unpleasantness of the toxic effect is as great 
as the hay-fever itself, rendering it an undesira- 
ble remedy. The same can be said of anti- 
pjrrin used internally. It must be given in 
large doses — ^^seven to eight grains 3 or 4 times 
daily for an adult. Its action is antispasmodic, 
and similar in effect to that in whooping cough. 
It is possible, and I believe this is true in many 
cases, it may act as an antitoxin to the irritant 
from the pollen, and in this way be of benefit 
when there are paroxysmal asthmatic symptoms. 

The iodids act well in small doses when the 
secretion is slight, but most patients are made 
worse by their use. Thyroid, in one grain doses, 
t. i. d., will increase the secretion, dilate the 
internal vessels and thus relieve the nasal con- 
gestion. The use of thyroid is usually effective 
in patients over 50 and when there is gout or 
rheumatism. 

The drugs mentioned above are at best only 
palliative and in no sense curative. From the 
report of Emmerich and Leow we can hope to 
cure the chronic tendency of hay-fever {Jour. 
A. M, A,, Jan. 17, 1915). They report five 
eases that were broken up and the patients 
[357] 



HAY-FEVEE 

permanently freed from its grip by continued 
treatment with calcium chlorid. This paper 
furnished us with the only positive internal rem- 
edy and is worthy of more extended trial. 



[358] 



BIBLIOGRAPHY 



[3590 



BIBLIOGEAPHY 

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Swearingen (D. D.), Treatment by Eemoving Nasal 

Obstruction. Southwestern Med., 5:12, April, '21. 
Walker (I. C), Frequent Causes and the Treatment of 

Seasonal Hay-Fever. Archives of Int. Med., 1921, 

xcviii, 71-118. 
Van Leeuken (W. S.) & Varekamp (H.), Tuberculin 

treatment of bronchial asthma and hay-fever. Lancet, 

2:1366, Dec. 31, 1921- 
Watson (S. H.) & Kibler (C. S.), Hay-fever Palliation; 

a New Use for the Influenza Mask. J. A. M. A., 

Chicago, 1921, Ixxvii, 1273. 
Williams (W. C), Hay-fever and Its Treatment with 

Pollen Extracts. Mil. Surgeon, Wash., 1921, xlix, 

421-429. 
Woldert (A. O.), A Further Keport on the Use of 

Pollen Extract Made bv the Author in the Treatment 

of Hay-fever. Texas State J. M., Fort Worth, 1921, 

xvii, 298-301. 

1922 

Dale (H. H.), Specific Sensitiveness and Anaphylaxis. 
Brit. Med. J., Lond., No. 3185, Jan. 14, 1922. 

Davison (H. M.), Case of Asthma Caused by Sensitive- 
ness to Dog Hair. Georgia Med. Ass. J., Atlanta, 
Vol. xi, No. 2, Feb, 1922. 

Hollopeter (W. C), Hay-fever: Its Prevention and 
Cure. 1922. Fourth Edition. Funk & Wagnalls 
Company, New York & London. 

Hutcheson (J. M.), Advantages and Limitations of 
Skin Tests for Protein Sensitization in Bronchial 
Asthma, Hay-fever and Allied Conditions. Virginia 
Med. Monthly, ^ol. 48, No. 11. Feb., 1922. 

Latham (A.), Some Aspects of Bronchial Asthma. 
Lancet, Lond., Vol. ccii, No. 5137, pp. 261-3. 

Mackenzie (G. M.), Desensitization of Hay-fever Pa- 
tients by Specific Local Applications. J. A. M. A., 
Vol. 78, No. 11. 

No Author Stated. Different Forms of Protein Sensiti- 
zation. Lancet, Lond., Vol. ccii, No. 5137, P. 290. 

Watson (S. H.), Etiology of Hay-fever in Arizona and 
the Southwest. J. A. M. A., VoL 78, No. 10. 

[412] 



INDEX 



INDEX 



Abbotts Smith, William, 27 
Adenoids, 148, 159 
Africa, Southwest, 186 
Adirondack Mountains, 196 
Age, influence of, 51, 121 
Albrecht, Th., 175, 194, 198 
Albumin as causative fac- 
tor, 31 

first reference to, 31 

kinds of, 105 

method of obtaining, 103 

theory, 31, 87 
Alexander, Dr., 355 
Allen, Harrison, 34, 132 
American Hay-Fever Pre- 
vention Association, 152 
Amylaceous indigestion, 165 
Anaphylaxis, 194 
Animal emanations, 285 
Anti-pyrin, 357 
Antipyrin, susceptibility to, 

194 
Antitoxin, hay-fever, 173 
Areas, sensitive nasal, 34, 

35, 68, 71 
Arnold, 41 
Arsenic, 172 
Articles forbidden, 169 
Ascaris megalocephala as a 

cause, 98 
Ash, 283 
Ashhurst, Samuel, 130 

[4 



Asthma as a late symptom, 

62 
Asthma, treatment of, 121 
Asthma, diagnosis from, 94 
Atlantic, cases on the, 114 
Atropia, 357 
Atropin sulfate, 171 
Australia, cases in, 113 
Auto-serum, 355 
Auto-suggestion, 50 
Autumnal catarrh, 19, 187 



B 



Bacteria may cause sea- 
sonal hay-fever, 285 
perennial hay-fever 
caused by, 333 

Bacteriologic study of nasal 
secretions, 103 

Ballinger, 148, 149, 345 

Barker, 298, 302 

Bath, tepid, 166 

Bayberry, 283 

Beard, G. M., 13, 32, 47, 48, 
55, 63, 69, 75, 80, 82, 
93, 111, 115, 118, 119, 
120, 124, 125 

Beecher, Henry Ward, 
cases in the family of, 
118 

Benzoic acid as a cause, 88, 
95 



15] 



INDEX 



Beschorner, 22 

Beverages, 168 

Bicycling, 167 

Binninger, 22 

Binz, C, 28 

Bishop, Seth S., 36, 134, 138 

Blackley, Chas. H., 29, 31, 

39, 90, 95, 102, 103, 122, 

184, 299 
experiments of, 90, 102 
Blue, Dr. Eupert, 154 
Bosworth, 49, 50, 52, 63, 72, 

76, 82, 119, 127, 129, 

132, 134 
Bostock, J., 19, 24, 88, 199 
Bostock's catarrh, 19 
Botallus, 22 
Bromids, susceptibility to, 

194 
Bronchitis, summer, 20 
BuUette, W. W., 83, 117 



Calcium chlorid, 347 
Calcium salt treatment, 346 
Canada, cases in, 115 
Capp, W. M., 70, 138 
Carbonate of iron, 165 
Catarrh, autumnal, 19, 187 

Bostock 's, 19 

nervous, 19 

pollen, 19 

pruritic, 19 

rose, 19 

summer, 20 
Cats, odors of, 192 

perennial hay-fever 
caused by, 324 
Causative factors, 31, 141 

[41 



Causes, 38 
accepted, 87 

ascaris megaloeephala, 98 
chocolate, 98 

coffee, 97 

dust, 46, 88, 93 

dust from books, 94 

emanations from dry hay, 
24, 96 

enteric fever, 44 

exciting, 38-40, 87 

fatigue, 24 

feathers, 97 

fruit, 96 

fungoid growth, 41 

hare, odor of, 98 

heat, 88, 89, 90, 96, 125 

indigestion, 143 

ipecac, 23, 35, 88, 97 

light, 32 

linseed meal, 96 

locust-tree blossoms, 97 

lyeopodium, 88, 97 

mango-tree, 137 

mattress, 100 

may-apple, 97 

mulberry blossoms, 97 

mustard, 96 

oak, 98 

obstruction of the nares, 
132 

ozone, 32, 88, 95 

peaches, odor of, 19, 100 

predisposing, 20, 21, 110 

ragweed, 105 

Eoman wormwood, 47 

sunshine, 24, 26 

toxin, 40 

of hay-fever, 21 
Changes in voice, 61 
Chaveau, 111 
6] 



I 



INDEX 



Chemical symptoms, 289 

Children, hay-fever in, 77 

Chills, analogy to recur- 
rence of, 50 

China, 186 

Chloric ether, 172 

Chocolate as a cause, 98 

Clark, Sir Andrew, 36 

Cleansing of the nares, 23 

Climate, 310 

Cocain, 105, 163 

Codein sulfate, 171 

Coffee as a cause, 97 

Cold, June, 19 
July, 19 

Conklin, 135 

Conlon, 342, 343 

Constipation, 165 

Cooke, 200 

Cornaz, 27 

Coryza, 302 

diagnosis from, 77 
nervous, 19 
periodica, 19, 34 
vasomotoria, 19 

Cottonwood, 282 

Crawfish, susceptibility to, 
194 

CuUen, 97 

Curtis, 199 

Cutaneous tests, 202, 319, 
320, 321, 324, 326, 328, 
329, 330, 332, 334, 335, 
336, 337, 338, 339, 347 
eruptions as complica- 
tions, 64 



Darwin, 108 

Daly, W. H., 33, 130 



Definition, 19 

Denmark, cases in, 113 

Desserts, 168 

Detweiler, H. K., 298 

Diagnosis, 65, 84 

Diagnosis, methods of, 306 

Diatheses, theory, 45, 81 

Diet, exercise and rest, 165. 

Difficult swallowing, 80 

Discharges, nasal, 59 

Distribution of cases in the 
United States, 53 

Dobeirs solution, 356 

Dogs, odors of, 192 

Domiciliary hygiene, 147 

Drenger, 99 

Dunbar, Prof. W. P., 173, 
175, 176, 199, 355 

Dunbar's serum, 172 

Duration, 51, 52 

During the season or cura- 
tive treatment with 
pollen, 263 

Dyspepsia, 165 

Dysphagia as a symptom, 
80 



E 



Ebstein, 135 

Eggs, 168 

EUiotson, 23, 25 

Elm, 282 

Emanations from dry hay 

as a cause, 24, 96 
Emmerich, 346, 347, 357 
England, distribution of 

cases in, 94 
Enlarged tonsils, 147, 148 
Erectile tissues, nasal, 69, 

72 



[417] 



INDEX 



Eruptions, skin, 64 
Eucain, 113, 163 
Exciting causes, 38, 40 
Experiments of Blackley on 

the pollen theory, 102 
Eye-symptoms, 59 



Farinaceous, 168 
Farrington, Dr. P. M., 354 
Fatigue as a cause, 24 
Faulty metabolism, 149 
Feathers as a cause, 97 
perennial hay-fever 

caused by, 325 
Fever during an attack, 56 
Fire Island, 196 
First recognition, 22 
Fish, 168 

Flowers, odors of, 192 
Floyer, John, 22 
Foods, perennial hay-fever 

caused by, 327 
Forms of treatment, 147 
France, cases in, 113 
Frank, 274 
Freeman, 200 
Frequent causes and the 

treatment of perennial 

hay-fever, 311 
seasonal hay-fever. 199 
Fruit as a cause, 96 
Fungoid growth as a cause, 

41 



G 



Gaslight, influence of, 92, 96 
General rules, 168 
Genito-urinary organs, in- 
volvement of, 61 

[41 



Georgian Bay, free from 
ragweed, 310 

German Hay-Fever Associa- 
tion, 175, 198 

Germans, rarity of cases 
among the, 111 

Germany, cases in, 113 

Gibbons, 82 

Goldenrod, pollen of, 187 

Good, 23 

Goodale, J. L., 200, 288, 
340, 355 

Grass pollen, 182 

Grasses, varieties of, causa- 
tive, 96, 105, 106 

Grayson, C. P., 37, 139, 141 

Gream, 25 

Green Mountains, 196 



Hack, 34, 62, 128, 131 

Haig, 135 

Hair as a cause, 304 

' ' Hair-caterpillar asthma, ' ' 

99 
Hare, odor of, as a cause, 

98 
Hay-asthma, 19 
Hay-fever antitoxin, 173 
caused by olfactory irri- 
tants, 288 
caused by the pollen of 

trees, 282 
causes of, 21 
defined, 20 
Hays, Dr. H., 355 
Heart, involvement of, 65 
Heat as a cause, 88, 89, 90, 

96, 125 
Helmholtz, 28, 41, 96 
8] 



INDEX 



Heligoland, 196 

Heredity, 149 

Hickory, 283 

History, 19 

Holman, 276 

Holmes, E. W., 37, 44, 57, 

75, 94, 109, 110, 122, 

123, 129, 133, 139 
Horseback riding, 167 
Horses, odor of, as a cause, 

98, 99 
perennial hay-fever 

caused by, 313 
Horton, Jacob, 31 
Hiinerswolff, 100 
Hydrogen dioxid, 161 
Hydrotherapeutic treat- 

ment, 172 
Hygiene, domiciliary, 147 

personal, 147 
Hypertophied tonsils, 159 



Idiosyncrasy, influence of, 

21, 128 
theory, 34 
Idiosyncratic coryza, 19 
Imagination, influence of, 

49, 101 
India, cases in, 113 
Indian, case in an, 111 
Indigestion, a m y 1 aceous, 

165 
as a cause, 143 
Individual predisposition, 

188, 191 
Ingals, 91, 164 
Insomnia as a symptom, 61 
Insurance, effect on, 80 
Intermittent fever, analogy 

to, 50 

[41 



Internasal treatment, 161 
lodid of potassium, 172 
lodids, 357 

lodin, susceptibility to, 194 
Ipecac as a cause, 23, 35, 88, 

97 
Iron, carbonate of, 165 
Italy, cases in, 113 
Itzigson, 97 
Ivy poisoning, analogy to, 

107 



Jacobi, 111 
June cold, 19 
Juniper, 282 
July cold, 19 



Kammann, Dr. O., 183 
Kinnear, 127 
Koessler, 200 



Labosse, 27 
Laforgue, 25 
Liefmann, 184, 186 
Life insurance, effect on, 80 
mode of, influence of, 122 
Light as a cause, 32 
Linden, odor of, 181 
Linseed meal as a cause, 96 
Local disease theory, 11, 37, 

130 
Local treatment by nasal 

applications, 158 
Locust-tree blossoms as a 

cause, 97 

9] 



INDEX 



Loew, 346, 347, 357 
Long Beach, 196 
Longevity, effect on, 81 
Lycopodium as a cause, 88, 
97 

M 

MacCuUoeh, 25 
Macdonald, 36, 55, 83, 99, 

113 
Mackenzie, J. N., 34, 50, 56, 

64, 68, 101, 112, 127, 

131, 133 
Mackenzie, Sir Morell, 35, 

52, 56, 65, 92, 100, 101, 

119, 120, 122, 128, 165 
Males, prevalence in, 40 
Mango-tree, as a cause, 107 
Manning, Dr., 355 
Marsh, 33, 105, 107 
Martin, 172 

Mattress as a cause, 100 
Mays, Thomas J., 135 
Meats, 168 

Mechanical symptoms, 289 
Medalia, 274 
Method of treating presea- 

sonally with pollen ex- 
tracts, 204 
of diagnosis, 306 
Micro-organisms in the 

nasal discharges, 40, 41 
Moore, George, 29 
Morrell, cases in family, 

118 
Mucous membrane, nasal, 

74 
Mulberry blossoms as a 

cause, 97 
MuUer, J., 143 
Murchison, 135 

[4 



Murrell, William, 99 

Muskoka, free from rag- 
weed, 310 

Mustard as a cause, 96 

Mutability of blossoming 
dates, 109 



N 



Name, origin of, 20, 23, 39 
Nares, cleansing of the, 23, 
169 
nervous supply to, 68 
sterilization of the, 169 
Nasal abnormalities as 
causes, 38, 132 
excretions, bacteriologic 

study of, 103 
symptoms, 58 
vasomotor control, 127 
Negro, case in a, 112 
Nervous coryza, 19 

supply to the nares, 68 
system, etiologic factor, 
32 
Nettle-rash as a complica- 
tion, 62 
Neurasthenic cases, 166 
Neurotic element, 36, 43, 
118, 139 
temperament, 118 
theory, 36, 44 
New England States, 206 
New Orleans, 157 
New Zealand, cases in, 113 
Noon, 200 

Norway, cases in, 113 
Nose, coldness of, 30, 55 
Nutrition, defect ive, a 

cause, 140 
Nux vomica, 165, 171 
20] 



INDEX 



Oak, 283 

Ocean, cases on the, 107, 

108 
Occupation, influence of, 

124 
Occurrence, time of, 27, 47, 

48, 52 
Odor of the linden, 181 
Odorific symptoms, 289 
Odors of fruit and flowers as 

a cause, 96 
Ohls, 164 

Olfactory vasomotor rhin- 
itis, 340, 345 
Onset, period of, 48 

symptoms of, 54, 56, 58 
Origin, 39 

nervous, first advanced, 

28 
of the name, 20, 23 
Other parts of plants that 

may cause hay-fever, 

284 
Other pollens that may 

cause hay-fever, 283 
Outdoor exercise, 165 



Parry, C. L., 23 

Pathology, 65, 84 

Patton, 182 

Peaches, odor of, as a 

cause, 19, 100 
Perennial hay-fever caused 
by bacteria, 333 
cats, 324 
feathers. 325 
foods, 327 
horses, 313 

[42 



pollens, 331 
unusual proteins, 332 
Personal hygiene, 147 

susceptibility, 35 
Phoebus, P., 26, 32, 49, 88, 

91, 95, 101, 120, 122 
Pine, 283 
Pirrie, William, 28, 32, 51, 

89, 91, 113 
Pneumonia as a complica- 
tion, 64 
Podophyllum as a cause, 97 
Poplars, 282 
Pollantin, 173, 299 
Pollen albumin, 191 
catarrh, 19 

during the season as cur- 
ative treatment with, 
263 
grass, 182 
of goldenrod, 187 
of ragweed, 187 
of trees, hay-fever caused 
by the, 282 
Pollens, perennial hay-fever 

caused by, 331 
Prater, Augustus, 25 
Predisposing causes, 20, 21, 

110 
Premonitory symptoms, 44, 

54, 89 
Present-day conception of 

hay-fever, 298 
Preventive measures, 147 
Prince, M., 50, 51, 119, 126 
Proctor, Eichard, case of, 

90 
Prognosis, 65, 80 
Protein sensitization, 299 
Protoplasmic substance as a 
cause, 43 

1] 



INDEX 



Pruritic eatarrli, 19 
rhinitis, 19 

Pruritis ani during an at- 
tack, 58 

Pulse during an attack, 58 

Psychic influence in the 
causation, 49, 101 



Quincaud, 135 
Quinin, 357 

salts of, susceptibility to, 

194 
solution as a remedy, 28, 

41 
valerianate of, 165 



Eace, influence of. 111 
Eagweed as an exciting 

cause, 42, 105 

common, 156 

fever, 19 

giant, 156 

pollen, 187 
Eamadge, 25 
Eecognition, first, 22 
Eectum, involvement of, 61 
Eecurrence, period of, 49 
Eegions of the nasal cav- 
ities, 66 
Eeport of cases, 286 
Eesistance, lowered, factor 
in, 39 

[42 



Ehinitis, olfactory vaso- 
motor, 340, 345 

spasmodic vasomotor, 302 

pruritic, 19 

sympathetica, 19 

vasomotoria, 19 
Eiedlin, 23 
Einger, 99 
Eoberts, 30, 55 
Eoe, J. O., 34, 70, 131 
Eoman wormwood as an 

exciting cause, 47 
Eose catarrh, 19 

cold, 19 
Eowing, 167 
Eussia, cases in, 113 



S 



Sajous, C. E. de M., 34, 44, 

54, 64, 66, 70, 111, 119, 

131 
Salter, Hyde, 26, 98 
Schadle, 148 
Scheppegrell, 150, 200, 274, 

355 
Scotland, eases in, 113 
Sea, cases at, 108 
Seasonal sensitive cases, 

302 
Selfridge, 200 
Sensitive areas of the 

nares, 45, 68 
Serum, nasal, 59 
Serums, the use of, 172 
Setschenow 's inhibitory 

center, 171 
Sex, influence of, 120 
Shaw, cases in family, 119 
Silver maple, 282 

2] 



INDEX 



Skin eruptions, 64 

Smell, involvement of, 59, 

65 
Smith, Abbotts, 27, 108, 110, 

114 
Ward, 96 
Sneezing in, 58 
Sodium phosphate, 165 
Solis-Cohen, S., 127, 129 
South America, eases in, 

113 
Southwest Africa, 186 
Spain, cases in, 113 
Spasmodic vasomotor rhi- 
nitis, 302 
Specific protein treatment, 

308 
Spontaneous disappearance 

of the recurrences, 83 
Sterilization of the nares, 

169 
Stimulants, 169 
Stramonium, 171 
Strangways, W. F., 42 
Strawberries, susceptibility 

to, 194 
Strouse, 274 
Strychnin, 357 
Suggestion, 192 
Summer bronchitis, 20 

catarrh, 20 
Sunlight, influence of, 25, 

92, 96 
Sunshine as a cause, 24, 26 
Surgical treatment, 353 
Susceptibility, personal, 35 
Swain, H. L., 164 
Swallowing, difficult, 80 
Sweden, cases in, 113 
Symptoms, 19, 53, 54, 56, 

65, 305 
chemical, 289 



mechanical, 289 
odorific, 289 
thermal, 289 
Synonyms, 19 



Taste, involvement of, 59, 65 
Tea-drinking, influence of, 

112 
Temperature during an at- 
tack, 57, 61 
Tepid bath, 166 
Term first used, 20, 23 
Theory, idiosyncrasy, 34 
local, 37, 132 
neurotic, 36, 44, 139 
pollen, 32 
uric-acid, 134 
Thermal symptoms, 289 
Thornwaldt, 133 
Thyroid, 357 
Timaeus, 23 
Time of occurrence, 27, 47, 

48, 52 
Tomatoes as a cause, 98 
Tonsils, h3rpertrophied, 159 
Toxin as a cause, 40 
Treatment, forms of, 147 
Treatment, surgical, 353 
Types, according to dura- 
tion, 52, 54 



U 



United States Department 
of Agriculture, 156 
distribution of cases in 
the, 53 

Urieacidemia, 171 



[ 423 



INDEX 



Uric-acid theory, 130, 134, 

137, 139 
Use of serums, 172 



Valerienate of quinin, 165 
Van Hebnont, 22 
Van Sweringen, 171 
Vasomotor control, nasal, 

127 
Vasomotor Coryza, 20 
susceptibility, theory of, 

126 
Veronal, 167 
Vibrios in the discharges, 

29 
Voice, changes in, 61 
Vogel, 96 



W 

Walker, Chandler, 199, 311 
Walking, 167 
Walsh, 27, 107, 114 
Water, 166 

Watermelons as a cause, 98 
Watson, Sir Thomas, 26, 97 
Weir-Mitchell, 167 
What hay-fever is, 19 
When asthma occurs as a 

sequel, 169 
White Mountains, 196 
Wilson, Harold, 346 
Wilson, J. C, 107 
Wyman, Morrill, 30, 31, 65, 

106, 111, 115, 118, 120, 

122 



[424] 



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